Florida Senate - 2009                             CS for SB 1658
       
       
       
       By the Committee on Health and Human Services Appropriations;
       and Senator Peaden
       
       
       
       603-03992-09                                          20091658c1
    1                        A bill to be entitled                      
    2         An act relating to the health care; amending s.
    3         408.040, F.S.; conforming a cross-reference; amending
    4         s. 409.814, F.S.; requiring an applicant for the
    5         Florida Kidcare program to provide verification of the
    6         child’s citizenship status; amending s. 409.815, F.S.;
    7         revising behavioral health services and dental
    8         services coverage under the Kidcare program; revising
    9         methods by which payments are made to federally
   10         qualified health centers and rural health clinics;
   11         amending s. 409.818, F.S.; revising the manner by
   12         which quality assurance and access standards are
   13         monitored in the Kidcare program; amending s. 409.904,
   14         F.S.; extending the date that certain persons are
   15         eligible to receive optional Medicaid services;
   16         amending s. 409.905, F.S.; requiring prior
   17         authorization for certain home health services;
   18         establishing requirements for Medicaid reimbursed home
   19         health services; revising the criteria for adjusting a
   20         hospital’s inpatient per diem rate; amending s.
   21         409.908, F.S.; requiring increases in certain Medicaid
   22         provider rates to be authorized in the appropriations
   23         act; amending s. 409.9082, F.S.; authorizing an
   24         exemption from the nursing home quality assessment to
   25         a nursing facility that has a certain number of
   26         indigent census days; deleting an option for
   27         discontinuing the nursing home quality assessment;
   28         amending s. 409.911, F.S.; updating the data to be
   29         used in calculating disproportionate share; amending
   30         s. 409.9112, F.S.; continuing the prohibition against
   31         distributing moneys under the perinatal intensive care
   32         centers disproportionate share program; amending s.
   33         409.9113, F.S.; continuing authorization for the
   34         distribution of moneys to teaching hospitals under the
   35         disproportionate share program; amending s. 409.9117,
   36         F.S.; continuing the prohibition against distributing
   37         moneys for the primary care disproportionate share
   38         program; amending ss. 409.91195 and 409.91196, F.S.;
   39         conforming cross-references; amending s. 409.912,
   40         F.S.; deleting the fixed payment for delivery program
   41         for Medicaid recipients 60 years of age or older;
   42         requiring that a Medicaid managed care plan’s costs to
   43         the state be adjusted for health status; amending s.
   44         409.91211, F.S.; revising the timeline for phasing in
   45         financial risk for provider service networks;
   46         conforming cross-references; amending s. 430.04, F.S.;
   47         requiring the Department of Elderly Affairs to
   48         administer all Medicaid waivers and programs relating
   49         to elders; amending s. 641.386, F.S.; conforming a
   50         cross-reference; directing the Agency for Health Care
   51         Administration to establish pilot projects in Miami
   52         Dade County relating to home health services;
   53         providing an effective date.
   54  
   55  Be It Enacted by the Legislature of the State of Florida:
   56  
   57         Section 1. Paragraph (d) of subsection (1) of section
   58  408.040, Florida Statutes, is amended to read:
   59         408.040 Conditions and monitoring.—
   60         (1)
   61         (d) If a nursing home is located in a county in which a
   62  long-term care community diversion pilot project has been
   63  implemented under s. 430.705 or in a county in which an
   64  integrated, fixed-payment delivery program for Medicaid
   65  recipients who are 60 years of age or older or dually eligible
   66  for Medicare and Medicaid has been implemented under s.
   67  409.912(5), the nursing home may request a reduction in the
   68  percentage of annual patient days used by residents who are
   69  eligible for care under Title XIX of the Social Security Act,
   70  which is a condition of the nursing home’s certificate of need.
   71  The agency shall automatically grant the nursing home’s request
   72  if the reduction is not more than 15 percent of the nursing
   73  home’s annual Medicaid-patient-days condition. A nursing home
   74  may submit only one request every 2 years for an automatic
   75  reduction. A requesting nursing home must notify the agency in
   76  writing at least 60 days in advance of its intent to reduce its
   77  annual Medicaid-patient-days condition by not more than 15
   78  percent. The agency must acknowledge the request in writing and
   79  must change its records to reflect the revised certificate-of
   80  need condition. This paragraph expires June 30, 2011.
   81         Section 2. Paragraph (c) is added to subsection (8) of
   82  section 409.814, Florida Statutes, to read:
   83         409.814 Eligibility.—A child who has not reached 19 years
   84  of age whose family income is equal to or below 200 percent of
   85  the federal poverty level is eligible for the Florida Kidcare
   86  program as provided in this section. For enrollment in the
   87  Children’s Medical Services Network, a complete application
   88  includes the medical or behavioral health screening. If,
   89  subsequently, an individual is determined to be ineligible for
   90  coverage, he or she must immediately be disenrolled from the
   91  respective Florida Kidcare program component.
   92         (8) In determining the eligibility of a child, an assets
   93  test is not required. Each applicant shall provide written
   94  documentation during the application process and the
   95  redetermination process, including, but not limited to, the
   96  following:
   97         (c)Effective January 1, 2010, verification of the child’s
   98  citizenship status as required under Title XXI of the Social
   99  Security Act.
  100         Section 3.  Paragraphs (g) and (q) of section (2) of
  101  section 409.815, Florida Statutes, are amended, and paragraph
  102  (w) is added to that section, to read:
  103         409.815  Health benefits coverage; limitations.—
  104         (2) BENCHMARK BENEFITS.—In order for health benefits
  105  coverage to qualify for premium assistance payments for an
  106  eligible child under ss. 409.810-409.820, the health benefits
  107  coverage, except for coverage under Medicaid and Medikids, must
  108  include the following minimum benefits, as medically necessary.
  109         (g) Behavioral health services.—
  110         1. Mental health benefits include:
  111         a. Inpatient services, limited to not more than 30
  112  inpatient days per contract year for psychiatric admissions, or
  113  residential services in facilities licensed under s. 394.875(6)
  114  or s. 395.003 in lieu of inpatient psychiatric admissions;
  115  however, a minimum of 10 of the 30 days shall be available only
  116  for inpatient psychiatric services if when authorized by a
  117  physician; and
  118         b. Outpatient services, including outpatient visits for
  119  psychological or psychiatric evaluation, diagnosis, and
  120  treatment by a licensed mental health professional, limited to a
  121  maximum of 40 outpatient visits each contract year.
  122         2. Substance abuse services include:
  123         a. Inpatient services, limited to not more than 7 inpatient
  124  days per contract year for medical detoxification only and 30
  125  days of residential services; and
  126         b. Outpatient services, including evaluation, diagnosis,
  127  and treatment by a licensed practitioner, limited to a maximum
  128  of 40 outpatient visits per contract year.
  129  
  130  Effective October 1, 2009, covered services include inpatient
  131  and outpatient services for mental and nervous disorders as
  132  defined in the most recent edition of the Diagnostic and
  133  Statistical Manual of Mental Disorders published by the American
  134  Psychiatric Association. Such benefits include psychological or
  135  psychiatric evaluation, diagnosis, and treatment by a licensed
  136  mental health professional, and inpatient, outpatient, and
  137  residential treatment services for the diagnosis and treatment
  138  of substance abuse disorders. Any benefit limitations, including
  139  duration of services, number of visits, or number of days for
  140  hospitalization or residential services may not be any less
  141  favorable than those for physical illnesses generally for the
  142  care and treatment of schizophrenia and psychotic disorders,
  143  mood disorders, anxiety disorders, substance abuse disorders,
  144  eating disorders, and childhood attention deficit disorders. The
  145  program may also implement appropriate financial incentives,
  146  peer review, utilization requirements, and other methods used
  147  for the management of benefits provided for other medical
  148  conditions in order to reduce service costs and utilization
  149  without compromising quality of care.
  150         (q) Dental services.Effective October 1, 2009, dental
  151  services shall be covered as required under federal law and may
  152  also include those dental benefits provided to children by the
  153  Florida Medicaid program under s. 409.906(6).
  154         (w)Reimbursement of federally qualified health centers and
  155  rural health clinics.—Effective October 1, 2009, payments for
  156  services provided to enrollees by federally qualified health
  157  centers and rural health clinics under this section shall be
  158  reimbursed using the Medicaid Prospective Payment System as
  159  provided for under s. 2107(e)(1)(D) of the Social Security Act,
  160  as added by subsection (a). If such services are paid for by
  161  health insurers or health care providers under contract with the
  162  Florida Healthy Kids Corporation, such entities are responsible
  163  for this payment. The agency may seek any available federal
  164  grants to assist with this transition.
  165         Section 4. Paragraph (c) of subsection (3) of section
  166  409.818, Florida Statutes, is amended to read:
  167         409.818 Administration.—In order to implement ss. 409.810
  168  409.820, the following agencies shall have the following duties:
  169         (3) The Agency for Health Care Administration, under the
  170  authority granted in s. 409.914(1), shall:
  171         (c) Monitor compliance with quality assurance and access
  172  standards developed under s. 409.820 and in accordance with s.
  173  2103(f) of the Social Security Act, 42 U.S.C. 1397bb(f).
  174  
  175  The agency is designated the lead state agency for Title XXI of
  176  the Social Security Act for purposes of receipt of federal
  177  funds, for reporting purposes, and for ensuring compliance with
  178  federal and state regulations and rules.
  179         Section 5. Subsection (1) and paragraph (a) of subsection
  180  (2) of section 409.904, Florida Statutes, are amended to read:
  181         409.904 Optional payments for eligible persons.—The agency
  182  may make payments for medical assistance and related services on
  183  behalf of the following persons who are determined to be
  184  eligible subject to the income, assets, and categorical
  185  eligibility tests set forth in federal and state law. Payment on
  186  behalf of these Medicaid eligible persons is subject to the
  187  availability of moneys and any limitations established by the
  188  General Appropriations Act or chapter 216.
  189         (1) Effective January 1, 2006, and Subject to federal
  190  waiver approval, a person who is age 65 or older or is
  191  determined to be disabled, whose income is at or below 88
  192  percent of the federal poverty level, whose assets do not exceed
  193  established limitations, and who is not eligible for Medicare
  194  or, if eligible for Medicare, is also eligible for and receiving
  195  Medicaid-covered institutional care services, hospice services,
  196  or home and community-based services. The agency shall seek
  197  federal authorization through a waiver to provide this coverage.
  198  This subsection expires December 31, 2010 June 30, 2009.
  199         (2)(a) A family, a pregnant woman, a child under age 21, a
  200  person age 65 or over, or a blind or disabled person, who would
  201  be eligible under any group listed in s. 409.903(1), (2), or
  202  (3), except that the income or assets of such family or person
  203  exceed established limitations. For a family or person in one of
  204  these coverage groups, medical expenses are deductible from
  205  income in accordance with federal requirements in order to make
  206  a determination of eligibility. A family or person eligible
  207  under the coverage known as the “medically needy,” is eligible
  208  to receive the same services as other Medicaid recipients, with
  209  the exception of services in skilled nursing facilities and
  210  intermediate care facilities for the developmentally disabled.
  211  This subsection expires December 31, 2010 June 30, 2009.
  212         Section 6. Subsection (4) and paragraph (c) of subsection
  213  (5) of section 409.905, Florida Statutes, are amended to read:
  214         409.905 Mandatory Medicaid services.—The agency may make
  215  payments for the following services, which are required of the
  216  state by Title XIX of the Social Security Act, furnished by
  217  Medicaid providers to recipients who are determined to be
  218  eligible on the dates on which the services were provided. Any
  219  service under this section shall be provided only when medically
  220  necessary and in accordance with state and federal law.
  221  Mandatory services rendered by providers in mobile units to
  222  Medicaid recipients may be restricted by the agency. Nothing in
  223  this section shall be construed to prevent or limit the agency
  224  from adjusting fees, reimbursement rates, lengths of stay,
  225  number of visits, number of services, or any other adjustments
  226  necessary to comply with the availability of moneys and any
  227  limitations or directions provided for in the General
  228  Appropriations Act or chapter 216.
  229         (4) HOME HEALTH CARE SERVICES.—The agency shall pay for
  230  nursing and home health aide services, supplies, appliances, and
  231  durable medical equipment, necessary to assist a recipient
  232  living at home. An entity that provides services pursuant to
  233  this subsection must shall be licensed under part III of chapter
  234  400. These services, equipment, and supplies, or reimbursement
  235  therefor, may be limited as provided in the General
  236  Appropriations Act and do not include services, equipment, or
  237  supplies provided to a person residing in a hospital or nursing
  238  facility.
  239         (a) In providing home health care services, the agency may
  240  require prior authorization of care based on diagnosis or
  241  utilization rates. Prior authorization is required for home
  242  health services visits not associated with a skilled nursing
  243  visit if the home health agency’s utilization rates exceed the
  244  state average by 50 percent or more. The home health agency must
  245  submit documentation that supports the recipient’s diagnosis and
  246  the recipient’s plan of care to the agency when requesting prior
  247  authorization.
  248         (b) The agency shall implement a comprehensive utilization
  249  management program that requires prior authorization of all
  250  private duty nursing services, an individualized treatment plan
  251  that includes information about medication and treatment orders,
  252  treatment goals, methods of care to be used, and plans for care
  253  coordination by nurses and other health professionals. The
  254  utilization management program shall also include a process for
  255  periodically reviewing the ongoing use of private duty nursing
  256  services. For a child, the assessment of need shall be based on
  257  a child’s condition, family support and care supplements, a
  258  family’s ability to provide care, and a family’s and child’s
  259  schedule regarding work, school, sleep, and care for other
  260  family dependents. When implemented, the private duty nursing
  261  utilization management program shall replace the current
  262  authorization program used by the agency for Health Care
  263  Administration and the Children’s Medical Services program of
  264  the Department of Health. The agency may competitively bid on a
  265  contract to select a qualified organization to provide
  266  utilization management of private duty nursing services. The
  267  agency is authorized to seek federal waivers to implement this
  268  initiative.
  269         (c)The agency may provide reimbursement for only those
  270  home health services that are medically necessary and if:
  271         1.The services are ordered by a physician.
  272         2.The written prescription for services is signed and
  273  dated by the recipient’s physician before the development of a
  274  plan of care and before any required request for prior
  275  authorization.
  276         3.The physician ordering the services is not employed,
  277  under contract with, or otherwise affiliated with the home
  278  health agency rendering the services.
  279         4.The physician ordering the services has examined the
  280  recipient within 30 days before the initial request for services
  281  and biannually thereafter.
  282         5.The written prescription for the services includes the
  283  recipient’s acute or chronic medical condition or diagnosis; the
  284  home health service required, including the minimum skill level
  285  required to perform the service; and the frequency and duration
  286  of services.
  287         6.The national provider identifier, Medicaid
  288  identification number, or medical practitioner license number of
  289  the physician ordering the services is listed on the written
  290  prescription for the services, the claim for home health
  291  reimbursement, and the prior authorization request.
  292         (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
  293  all covered services provided for the medical care and treatment
  294  of a recipient who is admitted as an inpatient by a licensed
  295  physician or dentist to a hospital licensed under part I of
  296  chapter 395. However, the agency shall limit the payment for
  297  inpatient hospital services for a Medicaid recipient 21 years of
  298  age or older to 45 days or the number of days necessary to
  299  comply with the General Appropriations Act.
  300         (c) The agency for Health Care Administration shall adjust
  301  a hospital’s current inpatient per diem rate to reflect the cost
  302  of serving the Medicaid population at that institution if:
  303         1. The hospital experiences an increase in Medicaid
  304  caseload by more than 25 percent in any year, primarily
  305  resulting from the closure of a hospital in the same service
  306  area occurring after July 1, 1995;
  307         2. The hospital’s Medicaid per diem rate is at least 25
  308  percent below the Medicaid per patient cost for that year; or
  309         3. The hospital is located in a county that has six five or
  310  fewer general acute care hospitals, began offering obstetrical
  311  services on or after September 1999, and has submitted a request
  312  in writing to the agency for a rate adjustment after July 1,
  313  2000, but before September 30, 2000, in which case such
  314  hospital’s Medicaid inpatient per diem rate shall be adjusted to
  315  cost, effective July 1, 2002.
  316  
  317  By No later than October 1 of each year, the agency must provide
  318  estimated costs for any adjustment in a hospital inpatient per
  319  diem rate pursuant to this paragraph to the Executive Office of
  320  the Governor, the House of Representatives General
  321  Appropriations Committee, and the Senate Appropriations
  322  Committee. Before the agency implements a change in a hospital’s
  323  inpatient per diem rate pursuant to this paragraph, the
  324  Legislature must have specifically appropriated sufficient funds
  325  in the General Appropriations Act to support the increase in
  326  cost as estimated by the agency.
  327         Section 7. Subsection (23) of section 409.908, Florida
  328  Statutes, is amended to read:
  329         409.908 Reimbursement of Medicaid providers.—Subject to
  330  specific appropriations, the agency shall reimburse Medicaid
  331  providers, in accordance with state and federal law, according
  332  to methodologies set forth in the rules of the agency and in
  333  policy manuals and handbooks incorporated by reference therein.
  334  These methodologies may include fee schedules, reimbursement
  335  methods based on cost reporting, negotiated fees, competitive
  336  bidding pursuant to s. 287.057, and other mechanisms the agency
  337  considers efficient and effective for purchasing services or
  338  goods on behalf of recipients. If a provider is reimbursed based
  339  on cost reporting and submits a cost report late and that cost
  340  report would have been used to set a lower reimbursement rate
  341  for a rate semester, then the provider’s rate for that semester
  342  shall be retroactively calculated using the new cost report, and
  343  full payment at the recalculated rate shall be effected
  344  retroactively. Medicare-granted extensions for filing cost
  345  reports, if applicable, shall also apply to Medicaid cost
  346  reports. Payment for Medicaid compensable services made on
  347  behalf of Medicaid eligible persons is subject to the
  348  availability of moneys and any limitations or directions
  349  provided for in the General Appropriations Act or chapter 216.
  350  Further, nothing in this section shall be construed to prevent
  351  or limit the agency from adjusting fees, reimbursement rates,
  352  lengths of stay, number of visits, or number of services, or
  353  making any other adjustments necessary to comply with the
  354  availability of moneys and any limitations or directions
  355  provided for in the General Appropriations Act, provided the
  356  adjustment is consistent with legislative intent.
  357         (23)(a) The agency shall establish rates at a level that
  358  ensures no increase in statewide expenditures resulting from a
  359  change in unit costs for 2 fiscal years effective July 1, 2009.
  360  Reimbursement rates for the 2 fiscal years shall be as provided
  361  in the General Appropriations Act.
  362         (a)(b)This subsection applies to The following provider
  363  types may not receive an increase in reimbursement rate due to a
  364  change in unit cost unless specifically appropriated in the
  365  General Appropriations Act:
  366         1. Inpatient hospitals.
  367         2. Outpatient hospitals.
  368         3. Nursing homes.
  369         4. County health departments.
  370         5. Community intermediate care facilities for the
  371  developmentally disabled.
  372         6. Prepaid health plans.
  373         7.Nursing home diversion programs.
  374  
  375  The agency shall apply the effect of this subsection to the
  376  reimbursement rates for nursing home diversion programs.
  377         (b)(c) The agency shall create a workgroup on hospital
  378  reimbursement, a workgroup on nursing facility reimbursement,
  379  and a workgroup on managed care plan payment. The workgroups
  380  shall evaluate alternative reimbursement and payment
  381  methodologies for hospitals, nursing facilities, and managed
  382  care plans, including prospective payment methodologies for
  383  hospitals and nursing facilities. The nursing facility workgroup
  384  shall also consider price-based methodologies for indirect care
  385  and acuity adjustments for direct care. The agency shall submit
  386  a report on the evaluated alternative reimbursement
  387  methodologies to the relevant committees of the Senate and the
  388  House of Representatives by November 1, 2009.
  389         (c)(d) This subsection expires June 30, 2011.
  390         Section 8. Paragraph (d) is added to subsection (3) of
  391  section 409.9082, Florida Statutes, as created by section 1 of
  392  chapter 2009-4, Laws of Florida, and subsection (6) of that
  393  section is amended, to read:
  394         409.9082 Quality assessment on nursing home facility
  395  providers; exemptions; purpose; federal approval required;
  396  remedies.—
  397         (3)
  398         (d)Effective July 1, 2009, the agency may exempt from the
  399  quality assessment or apply a lower quality assessment rate to a
  400  qualified public, nonstate owned or operated nursing home
  401  facility whose total annual indigent census days are greater
  402  than 25 percent of the facility’s total annual census days.
  403         (6) The quality assessment shall terminate and the agency
  404  shall discontinue the imposition, assessment, and collection of
  405  the nursing facility quality assessment if any of the following
  406  occur:
  407         (a) the agency does not obtain necessary federal approval
  408  for the nursing home facility quality assessment or the payment
  409  rates required by subsection (4); or
  410         (b)The weighted average Medicaid rate paid to nursing home
  411  facilities is reduced below the weighted average Medicaid rate
  412  to nursing home facilities in effect on December 31, 2008, plus
  413  any future annual amount of the quality assessment and the
  414  applicable matching federal funds. Upon termination of the
  415  quality assessment, all collected assessment revenues, less any
  416  amounts expended by the agency, shall be returned on a pro rata
  417  basis to the nursing facilities that paid them.
  418         Section 9. Paragraph (a) of subsection (2) of section
  419  409.911, Florida Statutes, is amended to read:
  420         409.911 Disproportionate share program.—Subject to specific
  421  allocations established within the General Appropriations Act
  422  and any limitations established pursuant to chapter 216, the
  423  agency shall distribute, pursuant to this section, moneys to
  424  hospitals providing a disproportionate share of Medicaid or
  425  charity care services by making quarterly Medicaid payments as
  426  required. Notwithstanding the provisions of s. 409.915, counties
  427  are exempt from contributing toward the cost of this special
  428  reimbursement for hospitals serving a disproportionate share of
  429  low-income patients.
  430         (2) The agency for Health Care Administration shall use the
  431  following actual audited data to determine the Medicaid days and
  432  charity care to be used in calculating the disproportionate
  433  share payment:
  434         (a) The average of the 2002, 2003, and 2004, and 2005
  435  audited disproportionate share data to determine each hospital’s
  436  Medicaid days and charity care for the 2009-2010 2008-2009 state
  437  fiscal year.
  438         Section 10. Section 409.9112, Florida Statutes, is amended
  439  to read:
  440         409.9112 Disproportionate share program for regional
  441  perinatal intensive care centers.—In addition to the payments
  442  made under s. 409.911, the agency for Health Care Administration
  443  shall design and implement a system for of making
  444  disproportionate share payments to those hospitals that
  445  participate in the regional perinatal intensive care center
  446  program established pursuant to chapter 383. The This system of
  447  payments must shall conform to with federal requirements and
  448  shall distribute funds in each fiscal year for which an
  449  appropriation is made by making quarterly Medicaid payments.
  450  Notwithstanding the provisions of s. 409.915, counties are
  451  exempt from contributing toward the cost of this special
  452  reimbursement for hospitals serving a disproportionate share of
  453  low-income patients. For the 2009-2010 state fiscal year 2008
  454  2009, the agency may shall not distribute moneys under the
  455  regional perinatal intensive care centers disproportionate share
  456  program.
  457         (1) The following formula shall be used by the agency to
  458  calculate the total amount earned for hospitals that participate
  459  in the regional perinatal intensive care center program:
  460                          TAE = HDSP/THDSP                         
  461  
  462         Where:
  463         TAE = total amount earned by a regional perinatal intensive
  464  care center.
  465         HDSP = the prior state fiscal year regional perinatal
  466  intensive care center disproportionate share payment to the
  467  individual hospital.
  468         THDSP = the prior state fiscal year total regional
  469  perinatal intensive care center disproportionate share payments
  470  to all hospitals.
  471         (2) The total additional payment for hospitals that
  472  participate in the regional perinatal intensive care center
  473  program shall be calculated by the agency as follows:
  474                           TAP = TAE x TA                          
  475  
  476         Where:
  477         TAP = total additional payment for a regional perinatal
  478  intensive care center.
  479         TAE = total amount earned by a regional perinatal intensive
  480  care center.
  481         TA = total appropriation for the regional perinatal
  482  intensive care center disproportionate share program.
  483         (3) In order to receive payments under this section, a
  484  hospital must be participating in the regional perinatal
  485  intensive care center program pursuant to chapter 383 and must
  486  meet the following additional requirements:
  487         (a) Agree to conform to all departmental and agency
  488  requirements to ensure high quality in the provision of
  489  services, including criteria adopted by departmental and agency
  490  rule concerning staffing ratios, medical records, standards of
  491  care, equipment, space, and such other standards and criteria as
  492  the department and agency deem appropriate as specified by rule.
  493         (b) Agree to provide information to the department and
  494  agency, in a form and manner to be prescribed by rule of the
  495  department and agency, concerning the care provided to all
  496  patients in neonatal intensive care centers and high-risk
  497  maternity care.
  498         (c) Agree to accept all patients for neonatal intensive
  499  care and high-risk maternity care, regardless of ability to pay,
  500  on a functional space-available basis.
  501         (d) Agree to develop arrangements with other maternity and
  502  neonatal care providers in the hospital’s region for the
  503  appropriate receipt and transfer of patients in need of
  504  specialized maternity and neonatal intensive care services.
  505         (e) Agree to establish and provide a developmental
  506  evaluation and services program for certain high-risk neonates,
  507  as prescribed and defined by rule of the department.
  508         (f) Agree to sponsor a program of continuing education in
  509  perinatal care for health care professionals within the region
  510  of the hospital, as specified by rule.
  511         (g) Agree to provide backup and referral services to the
  512  department’s county health departments and other low-income
  513  perinatal providers within the hospital’s region, including the
  514  development of written agreements between these organizations
  515  and the hospital.
  516         (h) Agree to arrange for transportation for high-risk
  517  obstetrical patients and neonates in need of transfer from the
  518  community to the hospital or from the hospital to another more
  519  appropriate facility.
  520         (4) Hospitals which fail to comply with any of the
  521  conditions in subsection (3) or the applicable rules of the
  522  department and agency may shall not receive any payments under
  523  this section until full compliance is achieved. A hospital which
  524  is not in compliance in two or more consecutive quarters may
  525  shall not receive its share of the funds. Any forfeited funds
  526  shall be distributed by the remaining participating regional
  527  perinatal intensive care center program hospitals.
  528         Section 11. Section 409.9113, Florida Statutes, is amended
  529  to read:
  530         409.9113 Disproportionate share program for teaching
  531  hospitals.—In addition to the payments made under ss. 409.911
  532  and 409.9112, the agency for Health Care Administration shall
  533  make disproportionate share payments to statutorily defined
  534  teaching hospitals for their increased costs associated with
  535  medical education programs and for tertiary health care services
  536  provided to the indigent. This system of payments must shall
  537  conform to with federal requirements and shall distribute funds
  538  in each fiscal year for which an appropriation is made by making
  539  quarterly Medicaid payments. Notwithstanding s. 409.915,
  540  counties are exempt from contributing toward the cost of this
  541  special reimbursement for hospitals serving a disproportionate
  542  share of low-income patients. For the 2009-2010 state fiscal
  543  year 2008-2009, the agency shall distribute the moneys provided
  544  in the General Appropriations Act to statutorily defined
  545  teaching hospitals and family practice teaching hospitals under
  546  the teaching hospital disproportionate share program. The funds
  547  provided for statutorily defined teaching hospitals shall be
  548  distributed in the same proportion as the state fiscal year
  549  2003-2004 teaching hospital disproportionate share funds were
  550  distributed or as otherwise provided in the General
  551  Appropriations Act. The funds provided for family practice
  552  teaching hospitals shall be distributed equally among family
  553  practice teaching hospitals.
  554         (1) On or before September 15 of each year, the agency for
  555  Health Care Administration shall calculate an allocation
  556  fraction to be used for distributing funds to state statutory
  557  teaching hospitals. Subsequent to the end of each quarter of the
  558  state fiscal year, the agency shall distribute to each statutory
  559  teaching hospital, as defined in s. 408.07, an amount determined
  560  by multiplying one-fourth of the funds appropriated for this
  561  purpose by the Legislature times such hospital’s allocation
  562  fraction. The allocation fraction for each such hospital shall
  563  be determined by the sum of the following three primary factors,
  564  divided by three. The primary factors are:
  565         (a) The number of nationally accredited graduate medical
  566  education programs offered by the hospital, including programs
  567  accredited by the Accreditation Council for Graduate Medical
  568  Education and the combined Internal Medicine and Pediatrics
  569  programs acceptable to both the American Board of Internal
  570  Medicine and the American Board of Pediatrics at the beginning
  571  of the state fiscal year preceding the date on which the
  572  allocation fraction is calculated. The numerical value of this
  573  factor is the fraction that the hospital represents of the total
  574  number of programs, where the total is computed for all state
  575  statutory teaching hospitals.
  576         (b) The number of full-time equivalent trainees in the
  577  hospital, which comprises two components:
  578         1. The number of trainees enrolled in nationally accredited
  579  graduate medical education programs, as defined in paragraph
  580  (a). Full-time equivalents are computed using the fraction of
  581  the year during which each trainee is primarily assigned to the
  582  given institution, over the state fiscal year preceding the date
  583  on which the allocation fraction is calculated. The numerical
  584  value of this factor is the fraction that the hospital
  585  represents of the total number of full-time equivalent trainees
  586  enrolled in accredited graduate programs, where the total is
  587  computed for all state statutory teaching hospitals.
  588         2. The number of medical students enrolled in accredited
  589  colleges of medicine and engaged in clinical activities,
  590  including required clinical clerkships and clinical electives.
  591  Full-time equivalents are computed using the fraction of the
  592  year during which each trainee is primarily assigned to the
  593  given institution, over the course of the state fiscal year
  594  preceding the date on which the allocation fraction is
  595  calculated. The numerical value of this factor is the fraction
  596  that the given hospital represents of the total number of full
  597  time equivalent students enrolled in accredited colleges of
  598  medicine, where the total is computed for all state statutory
  599  teaching hospitals.
  600  
  601  The primary factor for full-time equivalent trainees is computed
  602  as the sum of these two components, divided by two.
  603         (c) A service index that comprises three components:
  604         1. The Agency for Health Care Administration Service Index,
  605  computed by applying the standard Service Inventory Scores
  606  established by the agency for Health Care Administration to
  607  services offered by the given hospital, as reported on Worksheet
  608  A-2 for the last fiscal year reported to the agency before the
  609  date on which the allocation fraction is calculated. The
  610  numerical value of this factor is the fraction that the given
  611  hospital represents of the total Agency for Health Care
  612  Administration Service Index values, where the total is computed
  613  for all state statutory teaching hospitals.
  614         2. A volume-weighted service index, computed by applying
  615  the standard Service Inventory Scores established by the Agency
  616  for Health Care Administration to the volume of each service,
  617  expressed in terms of the standard units of measure reported on
  618  Worksheet A-2 for the last fiscal year reported to the agency
  619  before the date on which the allocation factor is calculated.
  620  The numerical value of this factor is the fraction that the
  621  given hospital represents of the total volume-weighted service
  622  index values, where the total is computed for all state
  623  statutory teaching hospitals.
  624         3. Total Medicaid payments to each hospital for direct
  625  inpatient and outpatient services during the fiscal year
  626  preceding the date on which the allocation factor is calculated.
  627  This includes payments made to each hospital for such services
  628  by Medicaid prepaid health plans, whether the plan was
  629  administered by the hospital or not. The numerical value of this
  630  factor is the fraction that each hospital represents of the
  631  total of such Medicaid payments, where the total is computed for
  632  all state statutory teaching hospitals.
  633  
  634  The primary factor for the service index is computed as the sum
  635  of these three components, divided by three.
  636         (2) By October 1 of each year, the agency shall use the
  637  following formula to calculate the maximum additional
  638  disproportionate share payment for statutorily defined teaching
  639  hospitals:
  640                           TAP = THAF x A                          
  641  
  642         Where:
  643         TAP = total additional payment.
  644         THAF = teaching hospital allocation factor.
  645         A = amount appropriated for a teaching hospital
  646  disproportionate share program.
  647         Section 12.  Section 409.9117, Florida Statutes, is amended
  648  to read:
  649         409.9117 Primary care disproportionate share program.—For
  650  the 2009-2010 state fiscal year 2008-2009, the agency shall not
  651  distribute moneys under the primary care disproportionate share
  652  program.
  653         (1) If federal funds are available for disproportionate
  654  share programs in addition to those otherwise provided by law,
  655  there shall be created a primary care disproportionate share
  656  program.
  657         (2) The following formula shall be used by the agency to
  658  calculate the total amount earned for hospitals that participate
  659  in the primary care disproportionate share program:
  660                          TAE = HDSP/THDSP                         
  661  
  662         Where:
  663         TAE = total amount earned by a hospital participating in
  664  the primary care disproportionate share program.
  665         HDSP = the prior state fiscal year primary care
  666  disproportionate share payment to the individual hospital.
  667         THDSP = the prior state fiscal year total primary care
  668  disproportionate share payments to all hospitals.
  669         (3) The total additional payment for hospitals that
  670  participate in the primary care disproportionate share program
  671  shall be calculated by the agency as follows:
  672                           TAP = TAE x TA                          
  673  
  674         Where:
  675         TAP = total additional payment for a primary care hospital.
  676         TAE = total amount earned by a primary care hospital.
  677         TA = total appropriation for the primary care
  678  disproportionate share program.
  679         (4) In the establishment and funding of this program, the
  680  agency shall use the following criteria in addition to those
  681  specified in s. 409.911, and payments may not be made to a
  682  hospital unless the hospital agrees to:
  683         (a) Cooperate with a Medicaid prepaid health plan, if one
  684  exists in the community.
  685         (b) Ensure the availability of primary and specialty care
  686  physicians to Medicaid recipients who are not enrolled in a
  687  prepaid capitated arrangement and who are in need of access to
  688  such physicians.
  689         (c) Coordinate and provide primary care services free of
  690  charge, except copayments, to all persons with incomes up to 100
  691  percent of the federal poverty level who are not otherwise
  692  covered by Medicaid or another program administered by a
  693  governmental entity, and to provide such services based on a
  694  sliding fee scale to all persons with incomes up to 200 percent
  695  of the federal poverty level who are not otherwise covered by
  696  Medicaid or another program administered by a governmental
  697  entity, except that eligibility may be limited to persons who
  698  reside within a more limited area, as agreed to by the agency
  699  and the hospital.
  700         (d) Contract with any federally qualified health center, if
  701  one exists within the agreed geopolitical boundaries, concerning
  702  the provision of primary care services, in order to guarantee
  703  delivery of services in a nonduplicative fashion, and to provide
  704  for referral arrangements, privileges, and admissions, as
  705  appropriate. The hospital shall agree to provide at an onsite or
  706  offsite facility primary care services within 24 hours to which
  707  all Medicaid recipients and persons eligible under this
  708  paragraph who do not require emergency room services are
  709  referred during normal daylight hours.
  710         (e) Cooperate with the agency, the county, and other
  711  entities to ensure the provision of certain public health
  712  services, case management, referral and acceptance of patients,
  713  and sharing of epidemiological data, as the agency and the
  714  hospital find mutually necessary and desirable to promote and
  715  protect the public health within the agreed geopolitical
  716  boundaries.
  717         (f) In cooperation with the county in which the hospital
  718  resides, develop a low-cost, outpatient, prepaid health care
  719  program to persons who are not eligible for the Medicaid
  720  program, and who reside within the area.
  721         (g) Provide inpatient services to residents within the area
  722  who are not eligible for Medicaid or Medicare, and who do not
  723  have private health insurance, regardless of ability to pay, on
  724  the basis of available space, except that hospitals may not be
  725  prevented nothing shall prevent the hospital from establishing
  726  bill collection programs based on ability to pay.
  727         (h) Work with the Florida Healthy Kids Corporation, the
  728  Florida Health Care Purchasing Cooperative, and business health
  729  coalitions, as appropriate, to develop a feasibility study and
  730  plan to provide a low-cost comprehensive health insurance plan
  731  to persons who reside within the area and who do not have access
  732  to such a plan.
  733         (i) Work with public health officials and other experts to
  734  provide community health education and prevention activities
  735  designed to promote healthy lifestyles and appropriate use of
  736  health services.
  737         (j) Work with the local health council to develop a plan
  738  for promoting access to affordable health care services for all
  739  persons who reside within the area, including, but not limited
  740  to, public health services, primary care services, inpatient
  741  services, and affordable health insurance generally.
  742  
  743  Any hospital that fails to comply with any of the provisions of
  744  this subsection, or any other contractual condition, may not
  745  receive payments under this section until full compliance is
  746  achieved.
  747         Section 13. Subsection (4) of section 409.91195, Florida
  748  Statutes, is amended to read:
  749         409.91195 Medicaid Pharmaceutical and Therapeutics
  750  Committee.—There is created a Medicaid Pharmaceutical and
  751  Therapeutics Committee within the agency for the purpose of
  752  developing a Medicaid preferred drug list.
  753         (4) Upon recommendation of the committee, the agency shall
  754  adopt a preferred drug list as described in s. 409.912(38) s.
  755  409.912(39). If To the extent feasible, the committee shall
  756  review all drug classes included on the preferred drug list
  757  every 12 months, and may recommend additions to and deletions
  758  from the preferred drug list, such that the preferred drug list
  759  provides for medically appropriate drug therapies for Medicaid
  760  patients which achieve cost savings contained in the General
  761  Appropriations Act.
  762         Section 14. Subsection (1) of section 409.91196, Florida
  763  Statutes, is amended to read:
  764         409.91196 Supplemental rebate agreements; public records
  765  and public meetings exemption.—
  766         (1) The rebate amount, percent of rebate, manufacturer’s
  767  pricing, and supplemental rebate, and other trade secrets as
  768  defined in s. 688.002 that the agency has identified for use in
  769  negotiations, held by the agency for Health Care Administration
  770  under s. 409.912(38)(a)7. s. 409.912(39)(a)7. are confidential
  771  and exempt from s. 119.07(1) and s. 24(a), Art. I of the State
  772  Constitution.
  773         Section 15. Present subsections (6) through (53) of section
  774  409.912, Florida Statutes, are redesignated as subsections (5)
  775  through (52), respectively, and present subsections (5), (21),
  776  and (29) of that section, are amended to read:
  777         409.912 Cost-effective purchasing of health care.—The
  778  agency shall purchase goods and services for Medicaid recipients
  779  in the most cost-effective manner consistent with the delivery
  780  of quality medical care. To ensure that medical services are
  781  effectively utilized, the agency may, in any case, require a
  782  confirmation or second physician’s opinion of the correct
  783  diagnosis for purposes of authorizing future services under the
  784  Medicaid program. This section does not restrict access to
  785  emergency services or poststabilization care services as defined
  786  in 42 C.F.R. part 438.114. Such confirmation or second opinion
  787  shall be rendered in a manner approved by the agency. The agency
  788  shall maximize the use of prepaid per capita and prepaid
  789  aggregate fixed-sum basis services when appropriate and other
  790  alternative service delivery and reimbursement methodologies,
  791  including competitive bidding pursuant to s. 287.057, designed
  792  to facilitate the cost-effective purchase of a case-managed
  793  continuum of care. The agency shall also require providers to
  794  minimize the exposure of recipients to the need for acute
  795  inpatient, custodial, and other institutional care and the
  796  inappropriate or unnecessary use of high-cost services. The
  797  agency shall contract with a vendor to monitor and evaluate the
  798  clinical practice patterns of providers in order to identify
  799  trends that are outside the normal practice patterns of a
  800  provider’s professional peers or the national guidelines of a
  801  provider’s professional association. The vendor must be able to
  802  provide information and counseling to a provider whose practice
  803  patterns are outside the norms, in consultation with the agency,
  804  to improve patient care and reduce inappropriate utilization.
  805  The agency may mandate prior authorization, drug therapy
  806  management, or disease management participation for certain
  807  populations of Medicaid beneficiaries, certain drug classes, or
  808  particular drugs to prevent fraud, abuse, overuse, and possible
  809  dangerous drug interactions. The Pharmaceutical and Therapeutics
  810  Committee shall make recommendations to the agency on drugs for
  811  which prior authorization is required. The agency shall inform
  812  the Pharmaceutical and Therapeutics Committee of its decisions
  813  regarding drugs subject to prior authorization. The agency is
  814  authorized to limit the entities it contracts with or enrolls as
  815  Medicaid providers by developing a provider network through
  816  provider credentialing. The agency may competitively bid single
  817  source-provider contracts if procurement of goods or services
  818  results in demonstrated cost savings to the state without
  819  limiting access to care. The agency may limit its network based
  820  on the assessment of beneficiary access to care, provider
  821  availability, provider quality standards, time and distance
  822  standards for access to care, the cultural competence of the
  823  provider network, demographic characteristics of Medicaid
  824  beneficiaries, practice and provider-to-beneficiary standards,
  825  appointment wait times, beneficiary use of services, provider
  826  turnover, provider profiling, provider licensure history,
  827  previous program integrity investigations and findings, peer
  828  review, provider Medicaid policy and billing compliance records,
  829  clinical and medical record audits, and other factors. Providers
  830  shall not be entitled to enrollment in the Medicaid provider
  831  network. The agency shall determine instances in which allowing
  832  Medicaid beneficiaries to purchase durable medical equipment and
  833  other goods is less expensive to the Medicaid program than long
  834  term rental of the equipment or goods. The agency may establish
  835  rules to facilitate purchases in lieu of long-term rentals in
  836  order to protect against fraud and abuse in the Medicaid program
  837  as defined in s. 409.913. The agency may seek federal waivers
  838  necessary to administer these policies.
  839         (5)The Agency for Health Care Administration, in
  840  partnership with the Department of Elderly Affairs, shall create
  841  an integrated, fixed-payment delivery program for Medicaid
  842  recipients who are 60 years of age or older or dually eligible
  843  for Medicare and Medicaid. The Agency for Health Care
  844  Administration shall implement the integrated program initially
  845  on a pilot basis in two areas of the state. The pilot areas
  846  shall be Area 7 and Area 11 of the Agency for Health Care
  847  Administration. Enrollment in the pilot areas shall be on a
  848  voluntary basis and in accordance with approved federal waivers
  849  and this section. The agency and its program contractors and
  850  providers shall not enroll any individual in the integrated
  851  program because the individual or the person legally responsible
  852  for the individual fails to choose to enroll in the integrated
  853  program. Enrollment in the integrated program shall be
  854  exclusively by affirmative choice of the eligible individual or
  855  by the person legally responsible for the individual. The
  856  integrated program must transfer all Medicaid services for
  857  eligible elderly individuals who choose to participate into an
  858  integrated-care management model designed to serve Medicaid
  859  recipients in the community. The integrated program must combine
  860  all funding for Medicaid services provided to individuals who
  861  are 60 years of age or older or dually eligible for Medicare and
  862  Medicaid into the integrated program, including funds for
  863  Medicaid home and community-based waiver services; all Medicaid
  864  services authorized in ss. 409.905 and 409.906, excluding funds
  865  for Medicaid nursing home services unless the agency is able to
  866  demonstrate how the integration of the funds will improve
  867  coordinated care for these services in a less costly manner; and
  868  Medicare coinsurance and deductibles for persons dually eligible
  869  for Medicaid and Medicare as prescribed in s. 409.908(13).
  870         (a)Individuals who are 60 years of age or older or dually
  871  eligible for Medicare and Medicaid and enrolled in the
  872  developmental disabilities waiver program, the family and
  873  supported-living waiver program, the project AIDS care waiver
  874  program, the traumatic brain injury and spinal cord injury
  875  waiver program, the consumer-directed care waiver program, and
  876  the program of all-inclusive care for the elderly program, and
  877  residents of institutional care facilities for the
  878  developmentally disabled, must be excluded from the integrated
  879  program.
  880         (b)Managed care entities who meet or exceed the agency’s
  881  minimum standards are eligible to operate the integrated
  882  program. Entities eligible to participate include managed care
  883  organizations licensed under chapter 641, including entities
  884  eligible to participate in the nursing home diversion program,
  885  other qualified providers as defined in s. 430.703(7), community
  886  care for the elderly lead agencies, and other state-certified
  887  community service networks that meet comparable standards as
  888  defined by the agency, in consultation with the Department of
  889  Elderly Affairs and the Office of Insurance Regulation, to be
  890  financially solvent and able to take on financial risk for
  891  managed care. Community service networks that are certified
  892  pursuant to the comparable standards defined by the agency are
  893  not required to be licensed under chapter 641. Managed care
  894  entities who operate the integrated program shall be subject to
  895  s. 408.7056. Eligible entities shall choose to serve enrollees
  896  who are dually eligible for Medicare and Medicaid, enrollees who
  897  are 60 years of age or older, or both.
  898         (c)The agency must ensure that the capitation-rate-setting
  899  methodology for the integrated program is actuarially sound and
  900  reflects the intent to provide quality care in the least
  901  restrictive setting. The agency must also require integrated
  902  program providers to develop a credentialing system for service
  903  providers and to contract with all Gold Seal nursing homes,
  904  where feasible, and exclude, where feasible, chronically poor
  905  performing facilities and providers as defined by the agency.
  906  The integrated program must develop and maintain an informal
  907  provider grievance system that addresses provider payment and
  908  contract problems. The agency shall also establish a formal
  909  grievance system to address those issues that were not resolved
  910  through the informal grievance system. The integrated program
  911  must provide that if the recipient resides in a noncontracted
  912  residential facility licensed under chapter 400 or chapter 429
  913  at the time of enrollment in the integrated program, the
  914  recipient must be permitted to continue to reside in the
  915  noncontracted facility as long as the recipient desires. The
  916  integrated program must also provide that, in the absence of a
  917  contract between the integrated-program provider and the
  918  residential facility licensed under chapter 400 or chapter 429,
  919  current Medicaid rates must prevail. The integrated-program
  920  provider must ensure that electronic nursing home claims that
  921  contain sufficient information for processing are paid within 10
  922  business days after receipt. Alternately, the integrated-program
  923  provider may establish a capitated payment mechanism to
  924  prospectively pay nursing homes at the beginning of each month.
  925  The agency and the Department of Elderly Affairs must jointly
  926  develop procedures to manage the services provided through the
  927  integrated program in order to ensure quality and recipient
  928  choice.
  929         (d)The Office of Program Policy Analysis and Government
  930  Accountability, in consultation with the Auditor General, shall
  931  comprehensively evaluate the pilot project for the integrated,
  932  fixed-payment delivery program for Medicaid recipients created
  933  under this subsection. The evaluation shall begin as soon as
  934  Medicaid recipients are enrolled in the managed care pilot
  935  program plans and shall continue for 24 months thereafter. The
  936  evaluation must include assessments of each managed care plan in
  937  the integrated program with regard to cost savings; consumer
  938  education, choice, and access to services; coordination of care;
  939  and quality of care. The evaluation must describe administrative
  940  or legal barriers to the implementation and operation of the
  941  pilot program and include recommendations regarding statewide
  942  expansion of the pilot program. The office shall submit its
  943  evaluation report to the Governor, the President of the Senate,
  944  and the Speaker of the House of Representatives no later than
  945  December 31, 2009.
  946         (e)The agency may seek federal waivers or Medicaid state
  947  plan amendments and adopt rules as necessary to administer the
  948  integrated program. The agency may implement the approved
  949  federal waivers and other provisions as specified in this
  950  subsection.
  951         (f)No later than December 31, 2007, the agency shall
  952  provide a report to the Governor, the President of the Senate,
  953  and the Speaker of the House of Representatives containing an
  954  analysis of the merits and challenges of seeking a waiver to
  955  implement a voluntary program that integrates payments and
  956  services for dually enrolled Medicare and Medicaid recipients
  957  who are 65 years of age or older.
  958         (20)(21) Any entity contracting with the agency pursuant to
  959  this section to provide health care services to Medicaid
  960  recipients is prohibited from engaging in any of the following
  961  practices or activities:
  962         (c) Granting or offering of any monetary or other valuable
  963  consideration for enrollment, except as authorized by subsection
  964  (23) (24).
  965         (28)(29) The agency shall perform enrollments and
  966  disenrollments for Medicaid recipients who are eligible for
  967  MediPass or managed care plans. Notwithstanding the prohibition
  968  contained in paragraph (20)(f) (21)(f), managed care plans may
  969  perform preenrollments of Medicaid recipients under the
  970  supervision of the agency or its agents. For the purposes of
  971  this section, “preenrollment” means the provision of marketing
  972  and educational materials to a Medicaid recipient and assistance
  973  in completing the application forms, but does shall not include
  974  actual enrollment into a managed care plan. An application for
  975  enrollment is shall not be deemed complete until the agency or
  976  its agent verifies that the recipient made an informed,
  977  voluntary choice. The agency, in cooperation with the Department
  978  of Children and Family Services, may test new marketing
  979  initiatives to inform Medicaid recipients about their managed
  980  care options at selected sites. The agency shall report to the
  981  Legislature on the effectiveness of such initiatives. The agency
  982  may contract with a third party to perform managed care plan and
  983  MediPass enrollment and disenrollment services for Medicaid
  984  recipients and may is authorized to adopt rules to implement
  985  such services. The agency may adjust the capitation rate only to
  986  cover the costs of a third-party enrollment and disenrollment
  987  contract, and for agency supervision and management of the
  988  managed care plan enrollment and disenrollment contract.
  989         Section 16. Paragraphs (e), (l), (p), and (w) of subsection
  990  (3) and subsection (12) of section 409.91211, Florida Statutes,
  991  are amended to read:
  992         409.91211 Medicaid managed care pilot program.—
  993         (3) The agency shall have the following powers, duties, and
  994  responsibilities with respect to the pilot program:
  995         (e) To implement policies and guidelines for phasing in
  996  financial risk for approved provider service networks over a 5-
  997  year 3-year period. These policies and guidelines must include
  998  an option for a provider service network to be paid fee-for
  999  service rates. For any provider service network established in a
 1000  managed care pilot area, the option to be paid fee-for-service
 1001  rates must shall include a savings-settlement mechanism that is
 1002  consistent with s. 409.912(44). This model must shall be
 1003  converted to a risk-adjusted capitated rate by no later than the
 1004  beginning of the sixth fourth year of operation, and may be
 1005  converted earlier at the option of the provider service network.
 1006  Federally qualified health centers may be offered an opportunity
 1007  to accept or decline a contract to participate in any provider
 1008  network for prepaid primary care services.
 1009         (l) To implement a system that prohibits capitated managed
 1010  care plans, their representatives, and providers employed by or
 1011  contracted with the capitated managed care plans from recruiting
 1012  persons eligible for or enrolled in Medicaid, from providing
 1013  inducements to Medicaid recipients to select a particular
 1014  capitated managed care plan, and from prejudicing Medicaid
 1015  recipients against other capitated managed care plans. The
 1016  system must shall require the entity performing choice
 1017  counseling to determine if the recipient has made a choice of a
 1018  plan or has opted out because of duress, threats, payment to the
 1019  recipient, or incentives promised to the recipient by a third
 1020  party. If the choice counseling entity determines that the
 1021  decision to choose a plan was unlawfully influenced or a plan
 1022  violated any of the provisions of s. 409.912(20) s. 409.912(21),
 1023  the choice counseling entity shall immediately report the
 1024  violation to the agency’s program integrity section for
 1025  investigation. Verification of choice counseling by the
 1026  recipient must shall include a stipulation that the recipient
 1027  acknowledges the provisions of this subsection.
 1028         (p) To implement standards for plan compliance, including,
 1029  but not limited to, standards for quality assurance and
 1030  performance improvement, standards for peer or professional
 1031  reviews, grievance policies, and policies for maintaining
 1032  program integrity. The agency shall develop a data-reporting
 1033  system, seek input from managed care plans in order to establish
 1034  requirements for patient-encounter reporting, and ensure that
 1035  the data reported is accurate and complete.
 1036         1. In performing the duties required under this section,
 1037  the agency shall work with managed care plans to establish a
 1038  uniform system to measure and monitor outcomes for a recipient
 1039  of Medicaid services.
 1040         2. The system must shall use financial, clinical, and other
 1041  criteria based on pharmacy, medical services, and other data
 1042  that is related to the provision of Medicaid services,
 1043  including, but not limited to:
 1044         a. The Health Plan Employer Data and Information Set
 1045  (HEDIS) or measures that are similar to HEDIS.
 1046         b. Member satisfaction.
 1047         c. Provider satisfaction.
 1048         d. Report cards on plan performance and best practices.
 1049         e. Compliance with the requirements for prompt payment of
 1050  claims under ss. 627.613, 641.3155, and 641.513.
 1051         f. Utilization and quality data for the purpose of ensuring
 1052  access to medically necessary services, including
 1053  underutilization or inappropriate denial of services.
 1054         3. The agency shall require the managed care plans that
 1055  have contracted with the agency to establish a quality assurance
 1056  system that incorporates the provisions of s. 409.912(26) s.
 1057  409.912(27) and any standards, rules, and guidelines developed
 1058  by the agency.
 1059         4. The agency shall establish an encounter database in
 1060  order to compile data on health services rendered by health care
 1061  practitioners who provide services to patients enrolled in
 1062  managed care plans in the demonstration sites. The encounter
 1063  database shall:
 1064         a. Collect the following for each type of patient encounter
 1065  with a health care practitioner or facility, including:
 1066         (I) The demographic characteristics of the patient.
 1067         (II) The principal, secondary, and tertiary diagnosis.
 1068         (III) The procedure performed.
 1069         (IV) The date and location where the procedure was
 1070  performed.
 1071         (V) The payment for the procedure, if any.
 1072         (VI) If applicable, the health care practitioner’s
 1073  universal identification number.
 1074         (VII) If the health care practitioner rendering the service
 1075  is a dependent practitioner, the modifiers appropriate to
 1076  indicate that the service was delivered by the dependent
 1077  practitioner.
 1078         b. Collect appropriate information relating to prescription
 1079  drugs for each type of patient encounter.
 1080         c. Collect appropriate information related to health care
 1081  costs and utilization from managed care plans participating in
 1082  the demonstration sites.
 1083         5. If To the extent practicable, when collecting the data
 1084  the agency shall use a standardized claim form or electronic
 1085  transfer system that is used by health care practitioners,
 1086  facilities, and payors.
 1087         6. Health care practitioners and facilities in the
 1088  demonstration sites shall electronically submit, and managed
 1089  care plans participating in the demonstration sites shall
 1090  electronically receive, information concerning claims payments
 1091  and any other information reasonably related to the encounter
 1092  database using a standard format as required by the agency.
 1093         7. The agency shall establish reasonable deadlines for
 1094  phasing in the electronic transmittal of full encounter data.
 1095         8. The system must ensure that the data reported is
 1096  accurate and complete.
 1097         (w) To implement procedures to minimize the risk of
 1098  Medicaid fraud and abuse in all plans operating in the Medicaid
 1099  managed care pilot program authorized in this section.
 1100         1. The agency shall ensure that applicable provisions of
 1101  this chapter and chapters 414, 626, 641, and 932 which relate to
 1102  Medicaid fraud and abuse are applied and enforced at the
 1103  demonstration project sites.
 1104         2. Providers must have the certification, license, and
 1105  credentials that are required by law and waiver requirements.
 1106         3. The agency shall ensure that the plan is in compliance
 1107  with s. 409.912(20) and (21) s. 409.912(21) and (22).
 1108         4. The agency shall require that each plan establish
 1109  functions and activities governing program integrity in order to
 1110  reduce the incidence of fraud and abuse. Plans must report
 1111  instances of fraud and abuse pursuant to chapter 641.
 1112         5. The plan must shall have written administrative and
 1113  management arrangements or procedures, including a mandatory
 1114  compliance plan, which are designed to guard against fraud and
 1115  abuse. The plan shall designate a compliance officer who has
 1116  sufficient experience in health care.
 1117         6.a. The agency shall require all managed care plan
 1118  contractors in the pilot program to report all instances of
 1119  suspected fraud and abuse. A failure to report instances of
 1120  suspected fraud and abuse is a violation of law and subject to
 1121  the penalties provided by law.
 1122         b. An instance of fraud and abuse in the managed care plan,
 1123  including, but not limited to, defrauding the state health care
 1124  benefit program by misrepresentation of fact in reports, claims,
 1125  certifications, enrollment claims, demographic statistics, or
 1126  patient-encounter data; misrepresentation of the qualifications
 1127  of persons rendering health care and ancillary services; bribery
 1128  and false statements relating to the delivery of health care;
 1129  unfair and deceptive marketing practices; and false claims
 1130  actions in the provision of managed care, is a violation of law
 1131  and subject to the penalties provided by law.
 1132         c. The agency shall require that all contractors make all
 1133  files and relevant billing and claims data accessible to state
 1134  regulators and investigators and that all such data is linked
 1135  into a unified system to ensure consistent reviews and
 1136  investigations.
 1137         (12) For purposes of this section, the term “capitated
 1138  managed care plan” includes health insurers authorized under
 1139  chapter 624, exclusive provider organizations authorized under
 1140  chapter 627, health maintenance organizations authorized under
 1141  chapter 641, the Children’s Medical Services Network under
 1142  chapter 391, and provider service networks that elect to be paid
 1143  fee-for-service for up to 5 3 years as authorized under this
 1144  section.
 1145         Section 17. Subsection (18) is added to section 430.04,
 1146  Florida Statutes, to read:
 1147         430.04 Duties and responsibilities of the Department of
 1148  Elderly Affairs.—The Department of Elderly Affairs shall:
 1149         (18)Administer all Medicaid waivers and programs relating
 1150  to elders and their appropriations. The waivers include, but are
 1151  not limited to:
 1152         (a)The Alzheimer’s Dementia-Specific Medicaid Waiver as
 1153  established in s. 430.502(7), (8), and (9).
 1154         (b)The Assisted Living for the Frail Elderly Waiver.
 1155         (c)The Aged and Disabled Adult Waiver.
 1156         (d)The Adult Day Health Care Waiver.
 1157         (e)The Consumer Directed Care Plus Program as defined in
 1158  s. 409.221.
 1159         (f)The Program for All-inclusive Care for the Elderly.
 1160         (g)The Long-Term Care Community-Based Diversion Pilot
 1161  Project as described in s. 430.705.
 1162         (h)The Channeling Services Waiver for Frail Elders.
 1163         Section 18. Subsection (4) of section 641.386, Florida
 1164  Statutes, is amended to read:
 1165         641.386 Agent licensing and appointment required;
 1166  exceptions.—
 1167         (4) All agents and health maintenance organizations must
 1168  shall comply with and be subject to the applicable provisions of
 1169  ss. 641.309 and 409.912(20) 409.912(21), and all companies and
 1170  entities appointing agents must shall comply with s. 626.451,
 1171  when marketing for any health maintenance organization licensed
 1172  pursuant to this part, including those organizations under
 1173  contract with the Agency for Health Care Administration to
 1174  provide health care services to Medicaid recipients or any
 1175  private entity providing health care services to Medicaid
 1176  recipients pursuant to a prepaid health plan contract with the
 1177  Agency for Health Care Administration.
 1178         Section 19. The Agency for Health Care Administration shall
 1179  develop and implement a home health agency monitoring pilot
 1180  project in Miami-Dade County by January 1, 2010. The agency
 1181  shall contract with a vendor to verify the utilization and the
 1182  delivery of home health services and provide an electronic
 1183  billing interface for such services. The contract must require
 1184  the creation of a program to submit claims for the home health
 1185  services electronically. The program must verify visits for the
 1186  delivery of home health services telephonically using voice
 1187  biometrics. The agency may seek amendments to the Medicaid state
 1188  plan and waivers of federal laws, as necessary, to implement the
 1189  pilot project. Notwithstanding s. 287.057(5)(f), Florida
 1190  Statutes, the agency must award the contract through the
 1191  competitive solicitation process. The agency shall submit a
 1192  report to the Governor, the President of the Senate, and the
 1193  Speaker of the House of Representatives evaluating the pilot
 1194  project by February 1, 2011.
 1195         Section 20. The Agency for Health Care Administration shall
 1196  implement a comprehensive care management pilot project in
 1197  Miami-Dade County for home health services by January 1, 2010,
 1198  which includes face-to-face assessments by a state-licensed
 1199  nurse, consultation with physicians ordering services to
 1200  substantiate the medical necessity for services, and on-site or
 1201  desk reviews of recipients’ medical records. The agency may
 1202  enter into a contract with a qualified organization to implement
 1203  the pilot project. The agency may seek amendments to the
 1204  Medicaid state plan and waivers of federal laws, as necessary,
 1205  to implement the pilot project.
 1206         Section 21. This act shall take effect upon becoming a law.


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