2010 Legislature            CS for CS for SB 1484, 2nd Engrossed
    2         An act relating to Medicaid; requiring that the Agency
    3         for Health Care Administration request an extension of
    4         a specified federal waiver; requiring the agency to
    5         report each month to the Legislature; requiring that
    6         certain changes of terms and conditions relating to
    7         the low-income pool be approved by the Legislative
    8         Budget Commission; requiring that the agency develop a
    9         methodology for intergovernmental transfers in any
   10         expansion of prepaid managed care in the Medicaid
   11         program; requiring that the secretary appoint a
   12         technical advisory panel; requiring a report to the
   13         Governor and Legislature; creating s. 624.35, F.S.;
   14         providing a short title; creating s. 624.351, F.S.;
   15         providing legislative findings; establishing the
   16         Medicaid and Public Assistance Fraud Strike Force
   17         within the Department of Financial Services to
   18         coordinate efforts to eliminate Medicaid and public
   19         assistance fraud; providing for membership; providing
   20         for meetings; specifying duties; requiring an annual
   21         report to the Legislature and Governor; creating s.
   22         624.352, F.S.; directing the Chief Financial Officer
   23         to prepare model interagency agreements that address
   24         Medicaid and public assistance fraud; specifying which
   25         agencies may be a party to such agreements; amending
   26         s. 16.59, F.S.; conforming provisions to changes made
   27         by the act; requiring the Divisions of Insurance Fraud
   28         and Public Assistance Fraud in the Department of
   29         Financial Services to be collocated with the Medicaid
   30         Fraud Control Unit if possible; requiring positions
   31         dedicated to Medicaid managed care fraud to be
   32         collocated with the Division of Insurance Fraud;
   33         amending s. 20.121, F.S.; establishing the Division of
   34         Public Assistance Fraud within the Department of
   35         Financial Services; amending ss. 411.01, 414.33, and
   36         414.39, F.S.; conforming provisions to changes made by
   37         the act; transferring, renumbering, and amending s.
   38         943.401, F.S.; directing the Department of Financial
   39         Services rather than the Department of Law Enforcement
   40         to investigate public assistance fraud; creating s.
   41         409.91212, F.S.; requiring that each managed care plan
   42         adopt an anti-fraud plan; specifying requirements for
   43         the plan; requiring that a managed care plan providing
   44         Medicaid services to establish and maintain a fraud
   45         investigative unit or contract for such services;
   46         providing requirements for reports to the Office of
   47         Medicaid Program Integrity; authorizing the agency to
   48         impose fines against a managed care plan that fails to
   49         submit an anti-fraud plan or make certain reports;
   50         authorizing the agency to adopt rules; directing the
   51         Auditor General and the Office of Program Policy
   52         Analysis and Government Accountability to review the
   53         Medicaid fraud and abuse processes in the Agency for
   54         Health Care Administration; requiring a report to the
   55         Legislature and Governor by a certain date;
   56         establishing the Medicaid claims adjudication project
   57         in the Agency for Health Care Administration to
   58         decrease the incidence of inaccurate payments and to
   59         improve the efficiency of the Medicaid claims
   60         processing system; amending s. 409.912, F.S.;
   61         authorizing the Agency for Health Care Administration
   62         to contract with an entity that provides comprehensive
   63         behavioral health care services to certain Medicaid
   64         recipients who are not enrolled in a Medicaid managed
   65         care plan or a Medicaid provider service network under
   66         certain circumstances; amending s. 409.91211, F.S.;
   67         revising certain provisions governing the Medicaid
   68         managed care pilot program to conform to the extension
   69         of the federal waiver; authorizing an administrative
   70         fee to be paid to the specialty plan for the
   71         coordination of services; transferring activities
   72         relating to public assistance fraud from the
   73         Department of Law Enforcement to the Division of
   74         Public Assistance Fraud in the Department of Financial
   75         Services by a type two transfer; providing effective
   76         dates.
   78  Be It Enacted by the Legislature of the State of Florida:
   80         Section 1. By July 1, 2010, the Agency for Health Care
   81  Administration shall begin the process of requesting an
   82  extension of the Section 1115 waiver and shall ensure that the
   83  waiver remains active and current. The agency shall report at
   84  least monthly to the Legislature on progress in negotiating for
   85  the extension of the waiver. Changes to the terms and conditions
   86  relating to the low-income pool must be approved by the
   87  Legislative Budget Commission.
   88         Section 2. (1)The Agency for Health Care Administration
   89  shall develop a methodology to ensure the availability of
   90  intergovernmental transfers in any expansion of prepaid managed
   91  care in the Medicaid program. The purpose of this methodology is
   92  to support providers that have historically served Medicaid
   93  recipients, including, but not limited to, safety net providers,
   94  trauma hospitals, children’s hospitals, statutory teaching
   95  hospitals, and medical and osteopathic physicians employed by or
   96  under contract with a medical school in this state. The agency
   97  may develop a supplemental capitation rate, risk pool, or
   98  incentive payment to plans that contract with these providers.
   99  The agency may develop the supplemental capitation rate to
  100  consider rates higher than the fee-for-service Medicaid rate
  101  when needed to ensure access and supported by funds provided by
  102  a locality. The agency shall evaluate the development of the
  103  rate cell to accurately reflect the underlying utilization to
  104  the maximum extent possible. The methodology may include interim
  105  rate adjustments as permitted under federal regulations. Any
  106  such methodology shall preserve federal funding to these
  107  entities and must be actuarially sound.
  108         (2)The Secretary of Health Care Administration shall
  109  appoint members and convene a technical advisory panel to advise
  110  the agency in the study and development of intergovernmental
  111  transfer distribution methods. The panel shall include
  112  representatives from contributing hospitals, medical schools,
  113  local governments, and managed care plans. The panel shall
  114  advise the agency regarding the best methods for ensuring the
  115  continued availability of intergovernmental transfers, specific
  116  issues to resolve in negotiations with the Centers for Medicare
  117  and Medicaid, and appropriate safeguards for appropriate
  118  implementation of any developed payment methodologies.
  119         (3)By January 1, 2011, the agency shall provide a report
  120  to the Speaker of the House of Representatives, the President of
  121  the Senate, and the Governor on the intergovernmental transfer
  122  methodologies developed. The agency shall not implement such
  123  methodologies without express legislative authority.
  124         Section 3. Section 624.35, Florida Statutes, is created to
  125  read:
  126         624.35Short title.—Sections 624.35-624.352 may be cited as
  127  the “Medicaid and Public Assistance Fraud Strike Force Act.”
  128         Section 4. Section 624.351, Florida Statutes, is created to
  129  read:
  130         624.351Medicaid and Public Assistance Fraud Strike Force.—
  131         (1)LEGISLATIVE FINDINGS.—The Legislature finds that there
  132  is a need to develop and implement a statewide strategy to
  133  coordinate state and local agencies, law enforcement entities,
  134  and investigative units in order to increase the effectiveness
  135  of programs and initiatives dealing with the prevention,
  136  detection, and prosecution of Medicaid and public assistance
  137  fraud.
  138         (2)ESTABLISHMENT.—The Medicaid and Public Assistance Fraud
  139  Strike Force is created within the department to oversee and
  140  coordinate state and local efforts to eliminate Medicaid and
  141  public assistance fraud and to recover state and federal funds.
  142  The strike force shall serve in an advisory capacity and provide
  143  recommendations and policy alternatives to the Chief Financial
  144  Officer.
  145         (3)MEMBERSHIP.—The strike force shall consist of the
  146  following 11 members who may not designate anyone to serve in
  147  their place:
  148         (a)The Chief Financial Officer, who shall serve as chair.
  149         (b)The Attorney General, who shall serve as vice chair.
  150         (c)The executive director of the Department of Law
  151  Enforcement.
  152         (d)The Secretary of Health Care Administration.
  153         (e)The Secretary of Children and Family Services.
  154         (f)The State Surgeon General.
  155         (g)Five members appointed by the Chief Financial Officer,
  156  consisting of two sheriffs, two chiefs of police, and one state
  157  attorney. When making these appointments, the Chief Financial
  158  Officer shall consider representation by geography, population,
  159  ethnicity, and other relevant factors in order to ensure that
  160  the membership of the strike force is representative of the
  161  state as a whole.
  163         (a)The five members appointed by the Chief Financial
  164  Officer shall be appointed to 4-year terms; however, for the
  165  purpose of providing staggered terms, of the initial
  166  appointments, two members shall be appointed to a 2-year term,
  167  two members shall be appointed to a 3-year term, and one member
  168  shall be appointed to a 4-year term. Each of the remaining
  169  members is a standing member of the strike force and may not
  170  serve beyond the time he or she holds the position that was the
  171  basis for strike force membership. A vacancy shall be filled in
  172  the same manner as the original appointment but only for the
  173  unexpired term.
  174         (b)The Legislature finds that the strike force serves a
  175  legitimate state, county, and municipal purpose and that service
  176  on the strike force is consistent with a member’s principal
  177  service in a public office or employment. Therefore membership
  178  on the strike force does not disqualify a member from holding
  179  any other public office or from being employed by a public
  180  entity, except that a member of the Legislature may not serve on
  181  the strike force.
  182         (c)Members of the strike force shall serve without
  183  compensation, but are entitled to reimbursement for per diem and
  184  travel expenses pursuant to s. 112.061. Reimbursements may be
  185  paid from appropriations provided to the department by the
  186  Legislature for the purposes of this section.
  187         (d)The Chief Financial Officer shall appoint a chief of
  188  staff for the strike force who must have experience, education,
  189  and expertise in the fields of law, prosecution, or fraud
  190  investigations and shall serve at the pleasure of the Chief
  191  Financial Officer. The department shall provide the strike force
  192  with staff necessary to assist the strike force in the
  193  performance of its duties.
  194         (5)MEETINGS.—The strike force shall hold its
  195  organizational session by March 1, 2011. Thereafter, the strike
  196  force shall meet at least four times per year. Additional
  197  meetings may be held if the chair determines that extraordinary
  198  circumstances require an additional meeting. Members may appear
  199  by electronic means. A majority of the members of the strike
  200  force constitutes a quorum.
  201         (6)STRIKE FORCE DUTIES.—The strike force shall provide
  202  advice and make recommendations, as necessary, to the Chief
  203  Financial Officer.
  204         (a)The strike force may advise the Chief Financial Officer
  205  on initiatives that include, but are not limited to:
  206         1.Conducting a census of local, state, and federal efforts
  207  to address Medicaid and public assistance fraud in this state,
  208  including fraud detection, prevention, and prosecution, in order
  209  to discern overlapping missions, maximize existing resources,
  210  and strengthen current programs.
  211         2.Developing a strategic plan for coordinating and
  212  targeting state and local resources for preventing and
  213  prosecuting Medicaid and public assistance fraud. The plan must
  214  identify methods to enhance multiagency efforts that contribute
  215  to achieving the state’s goal of eliminating Medicaid and public
  216  assistance fraud.
  217         3.Identifying methods to implement innovative technology
  218  and data sharing in order to detect and analyze Medicaid and
  219  public assistance fraud with speed and efficiency.
  220         4.Establishing a program to provide grants to state and
  221  local agencies that develop and implement effective Medicaid and
  222  public assistance fraud prevention, detection, and investigation
  223  programs, which are evaluated by the strike force and ranked by
  224  their potential to contribute to achieving the state’s goal of
  225  eliminating Medicaid and public assistance fraud. The grant
  226  program may also provide startup funding for new initiatives by
  227  local and state law enforcement or administrative agencies to
  228  combat Medicaid and public assistance fraud.
  229         5.Developing and promoting crime prevention services and
  230  educational programs that serve the public, including, but not
  231  limited to, a well-publicized rewards program for the
  232  apprehension and conviction of criminals who perpetrate Medicaid
  233  and public assistance fraud.
  234         6.Providing grants, contingent upon appropriation, for
  235  multiagency or state and local Medicaid and public assistance
  236  fraud efforts, which include, but are not limited to:
  237         a.Providing for a Medicaid and public assistance fraud
  238  prosecutor in the Office of the Statewide Prosecutor.
  239         b.Providing assistance to state attorneys for support
  240  services or equipment, or for the hiring of assistant state
  241  attorneys, as needed, to prosecute Medicaid and public
  242  assistance fraud cases.
  243         c.Providing assistance to judges for support services or
  244  for the hiring of senior judges, as needed, so that Medicaid and
  245  public assistance fraud cases can be heard expeditiously.
  246         (b)The strike force shall receive periodic reports from
  247  state agencies, law enforcement officers, investigators,
  248  prosecutors, and coordinating teams regarding Medicaid and
  249  public assistance criminal and civil investigations. Such
  250  reports may include discussions regarding significant factors
  251  and trends relevant to a statewide Medicaid and public
  252  assistance fraud strategy.
  253         (7)REPORTS.—The strike force shall annually prepare and
  254  submit a report on its activities and recommendations, by
  255  October 1, to the President of the Senate, the Speaker of the
  256  House of Representatives, the Governor, and the chairs of the
  257  House of Representatives and Senate committees that have
  258  substantive jurisdiction over Medicaid and public assistance
  259  fraud.
  260         Section 5. Section 624.352, Florida Statutes, is created to
  261  read:
  262         624.352Interagency agreements to detect and deter Medicaid
  263  and public assistance fraud.—
  264         (1)The Chief Financial Officer shall prepare model
  265  interagency agreements for the coordination of prevention,
  266  investigation, and prosecution of Medicaid and public assistance
  267  fraud to be known as “Strike Force” agreements. Parties to such
  268  agreements may include any agency that is headed by a Cabinet
  269  officer, the Governor, the Governor and Cabinet, a collegial
  270  body, or any federal, state, or local law enforcement agency.
  271         (2)The agreements must include, but are not limited to:
  272         (a)Establishing the agreement’s purpose, mission,
  273  authority, organizational structure, procedures, supervision,
  274  operations, deputations, funding, expenditures, property and
  275  equipment, reports and records, assets and forfeitures, media
  276  policy, liability, and duration.
  277         (b)Requiring that parties to an agreement have appropriate
  278  powers and authority relative to the purpose and mission of the
  279  agreement.
  280         Section 6. Section 16.59, Florida Statutes, is amended to
  281  read:
  282         16.59 Medicaid fraud control.—The Medicaid Fraud Control
  283  Unit There is created in the Department of Legal Affairs to the
  284  Medicaid Fraud Control Unit, which may investigate all
  285  violations of s. 409.920 and any criminal violations discovered
  286  during the course of those investigations. The Medicaid Fraud
  287  Control Unit may refer any criminal violation so uncovered to
  288  the appropriate prosecuting authority. The offices of the
  289  Medicaid Fraud Control Unit, and the offices of the Agency for
  290  Health Care Administration Medicaid program integrity program,
  291  and the Divisions of Insurance Fraud and Public Assistance Fraud
  292  within the Department of Financial Services shall, to the extent
  293  possible, be collocated; however, positions dedicated to
  294  Medicaid managed care fraud within the Medicaid Fraud Control
  295  Unit shall be collocated with the Division of Insurance Fraud.
  296  The Agency for Health Care Administration, and the Department of
  297  Legal Affairs, and the Divisions of Insurance Fraud and Public
  298  Assistance Fraud within the Department of Financial Services
  299  shall conduct joint training and other joint activities designed
  300  to increase communication and coordination in recovering
  301  overpayments.
  302         Section 7. Paragraph (o) is added to subsection (2) of
  303  section 20.121, Florida Statutes, to read:
  304         20.121 Department of Financial Services.—There is created a
  305  Department of Financial Services.
  306         (2) DIVISIONS.—The Department of Financial Services shall
  307  consist of the following divisions:
  308         (o)The Division of Public Assistance Fraud.
  309         Section 8. Paragraph (b) of subsection (7) of section
  310  411.01, Florida Statutes, is amended to read:
  311         411.01 School readiness programs; early learning
  312  coalitions.—
  313         (7) PARENTAL CHOICE.—
  314         (b) If it is determined that a provider has provided any
  315  cash to the beneficiary in return for receiving the purchase
  316  order, the early learning coalition or its fiscal agent shall
  317  refer the matter to the Department of Financial Services
  318  pursuant to s. 414.411 Division of Public Assistance Fraud for
  319  investigation.
  320         Section 9. Subsection (2) of section 414.33, Florida
  321  Statutes, is amended to read:
  322         414.33 Violations of food stamp program.—
  323         (2) In addition, the department shall establish procedures
  324  for referring to the Department of Law Enforcement any case that
  325  involves a suspected violation of federal or state law or rules
  326  governing the administration of the food stamp program to the
  327  Department of Financial Services pursuant to s. 414.411.
  328         Section 10. Subsection (9) of section 414.39, Florida
  329  Statutes, is amended to read:
  330         414.39 Fraud.—
  331         (9) All records relating to investigations of public
  332  assistance fraud in the custody of the department and the Agency
  333  for Health Care Administration are available for examination by
  334  the Department of Financial Services Law Enforcement pursuant to
  335  s. 414.411 943.401 and are admissible into evidence in
  336  proceedings brought under this section as business records
  337  within the meaning of s. 90.803(6).
  338         Section 11. Section 943.401, Florida Statutes, is
  339  transferred, renumbered as section 414.411, Florida Statutes,
  340  and amended to read:
  341         414.411 943.401 Public assistance fraud.—
  342         (1)(a) The Department of Financial Services Law Enforcement
  343  shall investigate all public assistance provided to residents of
  344  the state or provided to others by the state. In the course of
  345  such investigation the department of Law Enforcement shall
  346  examine all records, including electronic benefits transfer
  347  records and make inquiry of all persons who may have knowledge
  348  as to any irregularity incidental to the disbursement of public
  349  moneys, food stamps, or other items or benefits authorizations
  350  to recipients.
  351         (b) All public assistance recipients, as a condition
  352  precedent to qualification for public assistance received and as
  353  defined under the provisions of chapter 409, chapter 411, or
  354  this chapter 414, must shall first give in writing, to the
  355  Agency for Health Care Administration, the Department of Health,
  356  the Agency for Workforce Innovation, and the Department of
  357  Children and Family Services, as appropriate, and to the
  358  Department of Financial Services Law Enforcement, consent to
  359  make inquiry of past or present employers and records, financial
  360  or otherwise.
  361         (2) In the conduct of such investigation the Department of
  362  Financial Services Law Enforcement may employ persons having
  363  such qualifications as are useful in the performance of this
  364  duty.
  365         (3) The results of such investigation shall be reported by
  366  the Department of Financial Services Law Enforcement to the
  367  appropriate legislative committees, the Agency for Health Care
  368  Administration, the Department of Health, the Agency for
  369  Workforce Innovation, and the Department of Children and Family
  370  Services, and to such others as the department of Law
  371  Enforcement may determine.
  372         (4) The Department of Health and the Department of Children
  373  and Family Services shall report to the Department of Financial
  374  Services Law Enforcement the final disposition of all cases
  375  wherein action has been taken pursuant to s. 414.39, based upon
  376  information furnished by the Department of Financial Services
  377  Law Enforcement.
  378         (5) All lawful fees and expenses of officers and witnesses,
  379  expenses incident to taking testimony and transcripts of
  380  testimony and proceedings are a proper charge to the Department
  381  of Financial Services Law Enforcement.
  382         (6) The provisions of this section shall be liberally
  383  construed in order to carry out effectively the purposes of this
  384  section in the interest of protecting public moneys and other
  385  public property.
  386         Section 12. Section 409.91212, Florida Statutes, is created
  387  to read:
  388         409.91212Medicaid managed care fraud.—
  389         (1)Each managed care plan, as defined in s. 409.920(1)(e),
  390  shall adopt an anti-fraud plan addressing the detection and
  391  prevention of overpayments, abuse, and fraud relating to the
  392  provision of and payment for Medicaid services and submit the
  393  plan to the Office of Medicaid Program Integrity within the
  394  agency for approval. At a minimum, the anti-fraud plan must
  395  include:
  396         (a)A written description or chart outlining the
  397  organizational arrangement of the plan’s personnel who are
  398  responsible for the investigation and reporting of possible
  399  overpayment, abuse, or fraud;
  400         (b)A description of the plan’s procedures for detecting
  401  and investigating possible acts of fraud, abuse, and
  402  overpayment;
  403         (c)A description of the plan’s procedures for the
  404  mandatory reporting of possible overpayment, abuse, or fraud to
  405  the Office of Medicaid Program Integrity within the agency;
  406         (d)A description of the plan’s program and procedures for
  407  educating and training personnel on how to detect and prevent
  408  fraud, abuse, and overpayment;
  409         (e)The name, address, telephone number, e-mail address,
  410  and fax number of the individual responsible for carrying out
  411  the anti-fraud plan; and
  412         (f)A summary of the results of the investigations of
  413  fraud, abuse, or overpayment which were conducted during the
  414  previous year by the managed care organization’s fraud
  415  investigative unit.
  416         (2)A managed care plan that provides Medicaid services
  417  shall:
  418         (a)Establish and maintain a fraud investigative unit to
  419  investigate possible acts of fraud, abuse, and overpayment; or
  420         (b)Contract for the investigation of possible fraudulent
  421  or abusive acts by Medicaid recipients, persons providing
  422  services to Medicaid recipients, or any other persons.
  423         (3)If a managed care plan contracts for the investigation
  424  of fraudulent claims and other types of program abuse by
  425  recipients or service providers, the managed care plan shall
  426  file the following with the Office of Medicaid Program Integrity
  427  within the agency for approval before the plan executes any
  428  contracts for fraud and abuse prevention and detection:
  429         (a)A copy of the written contract between the plan and the
  430  contracting entity;
  431         (b) The names, addresses, telephone numbers, e-mail
  432  addresses, and fax numbers of the principals of the entity with
  433  which the managed care plan has contracted; and
  434         (c)A description of the qualifications of the principals
  435  of the entity with which the managed care plan has contracted.
  436         (4)On or before September 1 of each year, each managed
  437  care plan shall report to the Office of Medicaid Program
  438  Integrity within the agency on its experience in implementing an
  439  anti-fraud plan, as provided under subsection (1), and, if
  440  applicable, conducting or contracting for investigations of
  441  possible fraudulent or abusive acts as provided under this
  442  section for the prior state fiscal year. The report must
  443  include, at a minimum:
  444         (a)The dollar amount of losses and recoveries attributable
  445  to overpayment, abuse, and fraud.
  446         (b)The number of referrals to the Office of Medicaid
  447  Program Integrity during the prior year.
  448         (5)If a managed care plan fails to timely submit a final
  449  acceptable anti-fraud plan, fails to timely submit its annual
  450  report, fails to implement its anti-fraud plan or investigative
  451  unit, if applicable, or otherwise refuses to comply with this
  452  section, the agency shall impose:
  453         (a)An administrative fine of $2,000 per calendar day for
  454  failure to submit an acceptable anti-fraud plan or report until
  455  the agency deems the managed care plan or report to be in
  456  compliance;
  457         (b)An administrative fine of not more than $10,000 for
  458  failure by a managed care plan to implement an anti-fraud plan
  459  or investigative unit, as applicable; or
  460         (c)The administrative fines pursuant to paragraphs (a) and
  461  (b).
  462         (6)Each managed care plan shall report all suspected or
  463  confirmed instances of provider or recipient fraud or abuse
  464  within 15 calendar days after detection to the Office of
  465  Medicaid Program Integrity within the agency. At a minimum the
  466  report must contain the name of the provider or recipient, the
  467  Medicaid billing number or tax identification number, and a
  468  description of the fraudulent or abusive act. The Office of
  469  Medicaid Program Integrity in the agency shall forward the
  470  report of suspected overpayment, abuse, or fraud to the
  471  appropriate investigative unit, including, but not limited to,
  472  the Bureau of Medicaid program integrity, the Medicaid fraud
  473  control unit, the Division of Public Assistance Fraud, the
  474  Division of Insurance Fraud, or the Department of Law
  475  Enforcement.
  476         (a)Failure to timely report shall result in an
  477  administrative fine of $1,000 per calendar day after the 15th
  478  day of detection.
  479         (b)Failure to timely report may result in additional
  480  administrative, civil, or criminal penalties.
  481         (7)The agency may adopt rules to administer this section.
  482         Section 13. Review of the Medicaid fraud and abuse
  483  processes.—
  484         (1)The Auditor General and the Office of Program Policy
  485  Analysis and Government Accountability shall review and evaluate
  486  the Agency for Health Care Administration’s Medicaid fraud and
  487  abuse systems, including the Medicaid program integrity program.
  488  The reviewers may access Medicaid-related information and data
  489  from the Attorney General’s Medicaid Fraud Control Unit, the
  490  Department of Health, the Department of Elderly Affairs, the
  491  Agency for Persons with Disabilities, and the Department of
  492  Children and Family Services, as necessary, to conduct the
  493  review. The review must include, but is not limited to:
  494         (a)An evaluation of current Medicaid policies and the
  495  Medicaid fiscal agent;
  496         (b)An analysis of the Medicaid fraud and abuse prevention
  497  and detection processes, including agency contracts, Medicaid
  498  databases, and internal control risk assessments;
  499         (c)A comprehensive evaluation of the effectiveness of the
  500  current laws, rules, and contractual requirements that govern
  501  Medicaid managed care entities;
  502         (d)An evaluation of the agency’s Medicaid managed care
  503  oversight processes;
  504         (e)Recommendations to improve the Medicaid claims
  505  adjudication process, to increase the overall efficiency of the
  506  Medicaid program, and to reduce Medicaid overpayments; and
  507         (f)Operational and legislative recommendations to improve
  508  the prevention and detection of fraud and abuse in the Medicaid
  509  managed care program.
  510         (2)The Auditor General’s Office and the Office of Program
  511  Policy Analysis and Government Accountability may contract with
  512  technical consultants to assist in the performance of the
  513  review. The Auditor General and the Office of Program Policy
  514  Analysis and Government Accountability shall report to the
  515  President of the Senate, the Speaker of the House of
  516  Representatives, and the Governor by December 1, 2011.
  517         Section 14. Medicaid claims adjudication project.—The
  518  Agency for Health Care Administration shall issue a competitive
  519  procurement pursuant to chapter 287, Florida Statutes, with a
  520  third-party vendor, at no cost to the state, to provide a real
  521  time, front-end database to augment the Medicaid fiscal agent
  522  program edits and claims adjudication process. The vendor shall
  523  provide an interface with the Medicaid fiscal agent to decrease
  524  inaccurate payment to Medicaid providers and improve the overall
  525  efficiency of the Medicaid claims-processing system.
  526         Section 15. Effective July 1, 2010, paragraph (b) of
  527  subsection (4) of section 409.912, Florida Statutes, is amended,
  528  and paragraph (d) of that subsection is republished, to read:
  529         409.912 Cost-effective purchasing of health care.—The
  530  agency shall purchase goods and services for Medicaid recipients
  531  in the most cost-effective manner consistent with the delivery
  532  of quality medical care. To ensure that medical services are
  533  effectively utilized, the agency may, in any case, require a
  534  confirmation or second physician’s opinion of the correct
  535  diagnosis for purposes of authorizing future services under the
  536  Medicaid program. This section does not restrict access to
  537  emergency services or poststabilization care services as defined
  538  in 42 C.F.R. part 438.114. Such confirmation or second opinion
  539  shall be rendered in a manner approved by the agency. The agency
  540  shall maximize the use of prepaid per capita and prepaid
  541  aggregate fixed-sum basis services when appropriate and other
  542  alternative service delivery and reimbursement methodologies,
  543  including competitive bidding pursuant to s. 287.057, designed
  544  to facilitate the cost-effective purchase of a case-managed
  545  continuum of care. The agency shall also require providers to
  546  minimize the exposure of recipients to the need for acute
  547  inpatient, custodial, and other institutional care and the
  548  inappropriate or unnecessary use of high-cost services. The
  549  agency shall contract with a vendor to monitor and evaluate the
  550  clinical practice patterns of providers in order to identify
  551  trends that are outside the normal practice patterns of a
  552  provider’s professional peers or the national guidelines of a
  553  provider’s professional association. The vendor must be able to
  554  provide information and counseling to a provider whose practice
  555  patterns are outside the norms, in consultation with the agency,
  556  to improve patient care and reduce inappropriate utilization.
  557  The agency may mandate prior authorization, drug therapy
  558  management, or disease management participation for certain
  559  populations of Medicaid beneficiaries, certain drug classes, or
  560  particular drugs to prevent fraud, abuse, overuse, and possible
  561  dangerous drug interactions. The Pharmaceutical and Therapeutics
  562  Committee shall make recommendations to the agency on drugs for
  563  which prior authorization is required. The agency shall inform
  564  the Pharmaceutical and Therapeutics Committee of its decisions
  565  regarding drugs subject to prior authorization. The agency is
  566  authorized to limit the entities it contracts with or enrolls as
  567  Medicaid providers by developing a provider network through
  568  provider credentialing. The agency may competitively bid single
  569  source-provider contracts if procurement of goods or services
  570  results in demonstrated cost savings to the state without
  571  limiting access to care. The agency may limit its network based
  572  on the assessment of beneficiary access to care, provider
  573  availability, provider quality standards, time and distance
  574  standards for access to care, the cultural competence of the
  575  provider network, demographic characteristics of Medicaid
  576  beneficiaries, practice and provider-to-beneficiary standards,
  577  appointment wait times, beneficiary use of services, provider
  578  turnover, provider profiling, provider licensure history,
  579  previous program integrity investigations and findings, peer
  580  review, provider Medicaid policy and billing compliance records,
  581  clinical and medical record audits, and other factors. Providers
  582  shall not be entitled to enrollment in the Medicaid provider
  583  network. The agency shall determine instances in which allowing
  584  Medicaid beneficiaries to purchase durable medical equipment and
  585  other goods is less expensive to the Medicaid program than long
  586  term rental of the equipment or goods. The agency may establish
  587  rules to facilitate purchases in lieu of long-term rentals in
  588  order to protect against fraud and abuse in the Medicaid program
  589  as defined in s. 409.913. The agency may seek federal waivers
  590  necessary to administer these policies.
  591         (4) The agency may contract with:
  592         (b) An entity that is providing comprehensive behavioral
  593  health care services to certain Medicaid recipients through a
  594  capitated, prepaid arrangement pursuant to the federal waiver
  595  provided for by s. 409.905(5). Such entity must be licensed
  596  under chapter 624, chapter 636, or chapter 641, or authorized
  597  under paragraph (c) or paragraph (d), and must possess the
  598  clinical systems and operational competence to manage risk and
  599  provide comprehensive behavioral health care to Medicaid
  600  recipients. As used in this paragraph, the term “comprehensive
  601  behavioral health care services” means covered mental health and
  602  substance abuse treatment services that are available to
  603  Medicaid recipients. The secretary of the Department of Children
  604  and Family Services shall approve provisions of procurements
  605  related to children in the department’s care or custody before
  606  enrolling such children in a prepaid behavioral health plan. Any
  607  contract awarded under this paragraph must be competitively
  608  procured. In developing the behavioral health care prepaid plan
  609  procurement document, the agency shall ensure that the
  610  procurement document requires the contractor to develop and
  611  implement a plan to ensure compliance with s. 394.4574 related
  612  to services provided to residents of licensed assisted living
  613  facilities that hold a limited mental health license. Except as
  614  provided in subparagraph 8., and except in counties where the
  615  Medicaid managed care pilot program is authorized pursuant to s.
  616  409.91211, the agency shall seek federal approval to contract
  617  with a single entity meeting these requirements to provide
  618  comprehensive behavioral health care services to all Medicaid
  619  recipients not enrolled in a Medicaid managed care plan
  620  authorized under s. 409.91211, a provider service network
  621  authorized under paragraph (d), or a Medicaid health maintenance
  622  organization in an AHCA area. In an AHCA area where the Medicaid
  623  managed care pilot program is authorized pursuant to s.
  624  409.91211 in one or more counties, the agency may procure a
  625  contract with a single entity to serve the remaining counties as
  626  an AHCA area or the remaining counties may be included with an
  627  adjacent AHCA area and are subject to this paragraph. Each
  628  entity must offer a sufficient choice of providers in its
  629  network to ensure recipient access to care and the opportunity
  630  to select a provider with whom they are satisfied. The network
  631  shall include all public mental health hospitals. To ensure
  632  unimpaired access to behavioral health care services by Medicaid
  633  recipients, all contracts issued pursuant to this paragraph must
  634  require 80 percent of the capitation paid to the managed care
  635  plan, including health maintenance organizations and capitated
  636  provider service networks, to be expended for the provision of
  637  behavioral health care services. If the managed care plan
  638  expends less than 80 percent of the capitation paid for the
  639  provision of behavioral health care services, the difference
  640  shall be returned to the agency. The agency shall provide the
  641  plan with a certification letter indicating the amount of
  642  capitation paid during each calendar year for behavioral health
  643  care services pursuant to this section. The agency may reimburse
  644  for substance abuse treatment services on a fee-for-service
  645  basis until the agency finds that adequate funds are available
  646  for capitated, prepaid arrangements.
  647         1. By January 1, 2001, the agency shall modify the
  648  contracts with the entities providing comprehensive inpatient
  649  and outpatient mental health care services to Medicaid
  650  recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
  651  Counties, to include substance abuse treatment services.
  652         2. By July 1, 2003, the agency and the Department of
  653  Children and Family Services shall execute a written agreement
  654  that requires collaboration and joint development of all policy,
  655  budgets, procurement documents, contracts, and monitoring plans
  656  that have an impact on the state and Medicaid community mental
  657  health and targeted case management programs.
  658         3. Except as provided in subparagraph 8., by July 1, 2006,
  659  the agency and the Department of Children and Family Services
  660  shall contract with managed care entities in each AHCA area
  661  except area 6 or arrange to provide comprehensive inpatient and
  662  outpatient mental health and substance abuse services through
  663  capitated prepaid arrangements to all Medicaid recipients who
  664  are eligible to participate in such plans under federal law and
  665  regulation. In AHCA areas where eligible individuals number less
  666  than 150,000, the agency shall contract with a single managed
  667  care plan to provide comprehensive behavioral health services to
  668  all recipients who are not enrolled in a Medicaid health
  669  maintenance organization, a provider service network authorized
  670  under paragraph (d), or a Medicaid capitated managed care plan
  671  authorized under s. 409.91211. The agency may contract with more
  672  than one comprehensive behavioral health provider to provide
  673  care to recipients who are not enrolled in a Medicaid capitated
  674  managed care plan authorized under s. 409.91211, a provider
  675  service network authorized under paragraph (d), or a Medicaid
  676  health maintenance organization in AHCA areas where the eligible
  677  population exceeds 150,000. In an AHCA area where the Medicaid
  678  managed care pilot program is authorized pursuant to s.
  679  409.91211 in one or more counties, the agency may procure a
  680  contract with a single entity to serve the remaining counties as
  681  an AHCA area or the remaining counties may be included with an
  682  adjacent AHCA area and shall be subject to this paragraph.
  683  Contracts for comprehensive behavioral health providers awarded
  684  pursuant to this section shall be competitively procured. Both
  685  for-profit and not-for-profit corporations are eligible to
  686  compete. Managed care plans contracting with the agency under
  687  subsection (3) or paragraph (d), shall provide and receive
  688  payment for the same comprehensive behavioral health benefits as
  689  provided in AHCA rules, including handbooks incorporated by
  690  reference. In AHCA area 11, the agency shall contract with at
  691  least two comprehensive behavioral health care providers to
  692  provide behavioral health care to recipients in that area who
  693  are enrolled in, or assigned to, the MediPass program. One of
  694  the behavioral health care contracts must be with the existing
  695  provider service network pilot project, as described in
  696  paragraph (d), for the purpose of demonstrating the cost
  697  effectiveness of the provision of quality mental health services
  698  through a public hospital-operated managed care model. Payment
  699  shall be at an agreed-upon capitated rate to ensure cost
  700  savings. Of the recipients in area 11 who are assigned to
  701  MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
  702  MediPass-enrolled recipients shall be assigned to the existing
  703  provider service network in area 11 for their behavioral care.
  704         4. By October 1, 2003, the agency and the department shall
  705  submit a plan to the Governor, the President of the Senate, and
  706  the Speaker of the House of Representatives which provides for
  707  the full implementation of capitated prepaid behavioral health
  708  care in all areas of the state.
  709         a. Implementation shall begin in 2003 in those AHCA areas
  710  of the state where the agency is able to establish sufficient
  711  capitation rates.
  712         b. If the agency determines that the proposed capitation
  713  rate in any area is insufficient to provide appropriate
  714  services, the agency may adjust the capitation rate to ensure
  715  that care will be available. The agency and the department may
  716  use existing general revenue to address any additional required
  717  match but may not over-obligate existing funds on an annualized
  718  basis.
  719         c. Subject to any limitations provided in the General
  720  Appropriations Act, the agency, in compliance with appropriate
  721  federal authorization, shall develop policies and procedures
  722  that allow for certification of local and state funds.
  723         5. Children residing in a statewide inpatient psychiatric
  724  program, or in a Department of Juvenile Justice or a Department
  725  of Children and Family Services residential program approved as
  726  a Medicaid behavioral health overlay services provider may not
  727  be included in a behavioral health care prepaid health plan or
  728  any other Medicaid managed care plan pursuant to this paragraph.
  729         6. In converting to a prepaid system of delivery, the
  730  agency shall in its procurement document require an entity
  731  providing only comprehensive behavioral health care services to
  732  prevent the displacement of indigent care patients by enrollees
  733  in the Medicaid prepaid health plan providing behavioral health
  734  care services from facilities receiving state funding to provide
  735  indigent behavioral health care, to facilities licensed under
  736  chapter 395 which do not receive state funding for indigent
  737  behavioral health care, or reimburse the unsubsidized facility
  738  for the cost of behavioral health care provided to the displaced
  739  indigent care patient.
  740         7. Traditional community mental health providers under
  741  contract with the Department of Children and Family Services
  742  pursuant to part IV of chapter 394, child welfare providers
  743  under contract with the Department of Children and Family
  744  Services in areas 1 and 6, and inpatient mental health providers
  745  licensed pursuant to chapter 395 must be offered an opportunity
  746  to accept or decline a contract to participate in any provider
  747  network for prepaid behavioral health services.
  748         8. All Medicaid-eligible children, except children in area
  749  1 and children in Highlands County, Hardee County, Polk County,
  750  or Manatee County of area 6, that are open for child welfare
  751  services in the HomeSafeNet system, shall receive their
  752  behavioral health care services through a specialty prepaid plan
  753  operated by community-based lead agencies through a single
  754  agency or formal agreements among several agencies. The
  755  specialty prepaid plan must result in savings to the state
  756  comparable to savings achieved in other Medicaid managed care
  757  and prepaid programs. Such plan must provide mechanisms to
  758  maximize state and local revenues. The specialty prepaid plan
  759  shall be developed by the agency and the Department of Children
  760  and Family Services. The agency may seek federal waivers to
  761  implement this initiative. Medicaid-eligible children whose
  762  cases are open for child welfare services in the HomeSafeNet
  763  system and who reside in AHCA area 10 are exempt from the
  764  specialty prepaid plan upon the development of a service
  765  delivery mechanism for children who reside in area 10 as
  766  specified in s. 409.91211(3)(dd).
  767         (d) A provider service network may be reimbursed on a fee
  768  for-service or prepaid basis. A provider service network which
  769  is reimbursed by the agency on a prepaid basis shall be exempt
  770  from parts I and III of chapter 641, but must comply with the
  771  solvency requirements in s. 641.2261(2) and meet appropriate
  772  financial reserve, quality assurance, and patient rights
  773  requirements as established by the agency. Medicaid recipients
  774  assigned to a provider service network shall be chosen equally
  775  from those who would otherwise have been assigned to prepaid
  776  plans and MediPass. The agency is authorized to seek federal
  777  Medicaid waivers as necessary to implement the provisions of
  778  this section. Any contract previously awarded to a provider
  779  service network operated by a hospital pursuant to this
  780  subsection shall remain in effect for a period of 3 years
  781  following the current contract expiration date, regardless of
  782  any contractual provisions to the contrary. A provider service
  783  network is a network established or organized and operated by a
  784  health care provider, or group of affiliated health care
  785  providers, including minority physician networks and emergency
  786  room diversion programs that meet the requirements of s.
  787  409.91211, which provides a substantial proportion of the health
  788  care items and services under a contract directly through the
  789  provider or affiliated group of providers and may make
  790  arrangements with physicians or other health care professionals,
  791  health care institutions, or any combination of such individuals
  792  or institutions to assume all or part of the financial risk on a
  793  prospective basis for the provision of basic health services by
  794  the physicians, by other health professionals, or through the
  795  institutions. The health care providers must have a controlling
  796  interest in the governing body of the provider service network
  797  organization.
  798         Section 16. Effective July 1, 2010, paragraphs (e) and (dd)
  799  of subsection (3) of section 409.91211, Florida Statutes, are
  800  amended to read:
  801         409.91211 Medicaid managed care pilot program.—
  802         (3) The agency shall have the following powers, duties, and
  803  responsibilities with respect to the pilot program:
  804         (e) To implement policies and guidelines for phasing in
  805  financial risk for approved provider service networks that, for
  806  purposes of this paragraph, include the Children’s Medical
  807  Services Network, over the a 5-year period of the waiver and the
  808  extension thereof. These policies and guidelines must include an
  809  option for a provider service network to be paid fee-for-service
  810  rates. For any provider service network established in a managed
  811  care pilot area, the option to be paid fee-for-service rates
  812  must include a savings-settlement mechanism that is consistent
  813  with s. 409.912(44). This model must be converted to a risk
  814  adjusted capitated rate by the beginning of the final sixth year
  815  of operation under the waiver extension, and may be converted
  816  earlier at the option of the provider service network. Federally
  817  qualified health centers may be offered an opportunity to accept
  818  or decline a contract to participate in any provider network for
  819  prepaid primary care services.
  820         (dd) To implement service delivery mechanisms within a
  821  specialty plan in area 10 capitated managed care plans to
  822  provide behavioral health care services Medicaid services as
  823  specified in ss. 409.905 and 409.906 to Medicaid-eligible
  824  children whose cases are open for child welfare services in the
  825  HomeSafeNet system. These services must be coordinated with
  826  community-based care providers as specified in s. 409.1671,
  827  where available, and be sufficient to meet the medical,
  828  developmental, behavioral, and emotional needs of these
  829  children. Children in area 10 who have an open case in the
  830  HomeSafeNet system shall be enrolled into the specialty plan.
  831  These service delivery mechanisms must be implemented no later
  832  than July 1, 2011 2008, in AHCA area 10 in order for the
  833  children in AHCA area 10 to remain exempt from the statewide
  834  plan under s. 409.912(4)(b)8. An administrative fee may be paid
  835  to the specialty plan for the coordination of services based on
  836  the receipt of the state share of that fee being provided
  837  through intergovernmental transfers.
  838         Section 17. All powers, duties, functions, records,
  839  offices, personnel, property, pending issues and existing
  840  contracts, administrative authority, administrative rules, and
  841  unexpended balances of appropriations, allocations, and other
  842  funds relating to public assistance fraud in the Department of
  843  Law Enforcement are transferred by a type two transfer, as
  844  defined in s. 20.06(2), Florida Statutes, to the Division of
  845  Public Assistance Fraud in the Department of Financial Services.
  846         Section 18. Except as otherwise expressly provided in this
  847  act and except for sections 1, 2, 12, 13, and 14 of this act and
  848  this section, which shall take effect upon this act becoming a
  849  law, this act shall take effect January 1, 2011.

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