Amendment CaShTmL-653330.HTM
    Florida Senate - 2005                        SENATOR AMENDMENT
    Bill No. CS for CS for SB 838, 1st Eng.
                        Barcode 653330
                            CHAMBER ACTION
              Senate                               House
                                   .                    
                                   .                    
 1                  1/AD/3R        .                    
       05/06/2005 07:45 PM         .                    
 2                                 .                    
                                   .                    
 3                                 .                    
                                   .                    
 4  ______________________________________________________________
 5  
 6  
 7  
 8  
 9  
10  ______________________________________________________________
11  Senators Peaden, Carlton, Saunders, Atwater, Campbell, and
12  Rich moved the following amendment:
13  
14         Senate Amendment (with title amendment) 
15         Delete everything after the enacting clause
16  
17  and insert:  
18         Section 1.  Section 409.912, Florida Statutes, is
19  amended to read:
20         409.912  Cost-effective purchasing of health care.--The
21  agency shall purchase goods and services for Medicaid
22  recipients in the most cost-effective manner consistent with
23  the delivery of quality medical care. To ensure that medical
24  services are effectively utilized, the agency may, in any
25  case, require a confirmation or second physician's opinion of
26  the correct diagnosis for purposes of authorizing future
27  services under the Medicaid program. This section does not
28  restrict access to emergency services or poststabilization
29  care services as defined in 42 C.F.R. part 438.114. Such
30  confirmation or second opinion shall be rendered in a manner
31  approved by the agency. The agency shall maximize the use of
                                  1
    6:35 PM   05/06/05                             s0838e1c-02-j32

Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 prepaid per capita and prepaid aggregate fixed-sum basis 2 services when appropriate and other alternative service 3 delivery and reimbursement methodologies, including 4 competitive bidding pursuant to s. 287.057, designed to 5 facilitate the cost-effective purchase of a case-managed 6 continuum of care. The agency shall also require providers to 7 minimize the exposure of recipients to the need for acute 8 inpatient, custodial, and other institutional care and the 9 inappropriate or unnecessary use of high-cost services. The 10 agency shall contract with a vendor to monitor and evaluate 11 the clinical practice patterns of providers in order to 12 identify trends that are outside the normal practice patterns 13 of a provider's professional peers or the national guidelines 14 of a provider's professional association. The vendor must be 15 able to provide information and counseling to a provider whose 16 practice patterns are outside the norms, in consultation with 17 the agency, to improve patient care and reduce inappropriate 18 utilization. The agency may mandate prior authorization, drug 19 therapy management, or disease management participation for 20 certain populations of Medicaid beneficiaries, certain drug 21 classes, or particular drugs to prevent fraud, abuse, overuse, 22 and possible dangerous drug interactions. The Pharmaceutical 23 and Therapeutics Committee shall make recommendations to the 24 agency on drugs for which prior authorization is required. The 25 agency shall inform the Pharmaceutical and Therapeutics 26 Committee of its decisions regarding drugs subject to prior 27 authorization. The agency is authorized to limit the entities 28 it contracts with or enrolls as Medicaid providers by 29 developing a provider network through provider credentialing. 30 The agency may competitively bid single-source-provider 31 contracts if procurement of goods or services results in 2 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 demonstrated cost savings to the state without limiting access 2 to care. The agency may limit its network based on the 3 assessment of beneficiary access to care, provider 4 availability, provider quality standards, time and distance 5 standards for access to care, the cultural competence of the 6 provider network, demographic characteristics of Medicaid 7 beneficiaries, practice and provider-to-beneficiary standards, 8 appointment wait times, beneficiary use of services, provider 9 turnover, provider profiling, provider licensure history, 10 previous program integrity investigations and findings, peer 11 review, provider Medicaid policy and billing compliance 12 records, clinical and medical record audits, and other 13 factors. Providers shall not be entitled to enrollment in the 14 Medicaid provider network. The agency shall determine 15 instances in which allowing Medicaid beneficiaries to purchase 16 durable medical equipment and other goods is less expensive to 17 the Medicaid program than long-term rental of the equipment or 18 goods. The agency may establish rules to facilitate purchases 19 in lieu of long-term rentals in order to protect against fraud 20 and abuse in the Medicaid program as defined in s. 409.913. 21 The agency may is authorized to seek federal waivers necessary 22 to administer these policies implement this policy. 23 (1) The agency shall work with the Department of 24 Children and Family Services to ensure access of children and 25 families in the child protection system to needed and 26 appropriate mental health and substance abuse services. 27 (2) The agency may enter into agreements with 28 appropriate agents of other state agencies or of any agency of 29 the Federal Government and accept such duties in respect to 30 social welfare or public aid as may be necessary to implement 31 the provisions of Title XIX of the Social Security Act and ss. 3 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 409.901-409.920. 2 (3) The agency may contract with health maintenance 3 organizations certified pursuant to part I of chapter 641 for 4 the provision of services to recipients. 5 (4) The agency may contract with: 6 (a) An entity that provides no prepaid health care 7 services other than Medicaid services under contract with the 8 agency and which is owned and operated by a county, county 9 health department, or county-owned and operated hospital to 10 provide health care services on a prepaid or fixed-sum basis 11 to recipients, which entity may provide such prepaid services 12 either directly or through arrangements with other providers. 13 Such prepaid health care services entities must be licensed 14 under parts I and III by January 1, 1998, and until then are 15 exempt from the provisions of part I of chapter 641. An entity 16 recognized under this paragraph which demonstrates to the 17 satisfaction of the Office of Insurance Regulation of the 18 Financial Services Commission that it is backed by the full 19 faith and credit of the county in which it is located may be 20 exempted from s. 641.225. 21 (b) An entity that is providing comprehensive 22 behavioral health care services to certain Medicaid recipients 23 through a capitated, prepaid arrangement pursuant to the 24 federal waiver provided for by s. 409.905(5). Such an entity 25 must be licensed under chapter 624, chapter 636, or chapter 26 641 and must possess the clinical systems and operational 27 competence to manage risk and provide comprehensive behavioral 28 health care to Medicaid recipients. As used in this paragraph, 29 the term "comprehensive behavioral health care services" means 30 covered mental health and substance abuse treatment services 31 that are available to Medicaid recipients. The secretary of 4 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 the Department of Children and Family Services shall approve 2 provisions of procurements related to children in the 3 department's care or custody prior to enrolling such children 4 in a prepaid behavioral health plan. Any contract awarded 5 under this paragraph must be competitively procured. In 6 developing the behavioral health care prepaid plan procurement 7 document, the agency shall ensure that the procurement 8 document requires the contractor to develop and implement a 9 plan to ensure compliance with s. 394.4574 related to services 10 provided to residents of licensed assisted living facilities 11 that hold a limited mental health license. Except as provided 12 in subparagraph 8., the agency shall seek federal approval to 13 contract with a single entity meeting these requirements to 14 provide comprehensive behavioral health care services to all 15 Medicaid recipients not enrolled in a managed care plan in an 16 AHCA area. Each entity must offer sufficient choice of 17 providers in its network to ensure recipient access to care 18 and the opportunity to select a provider with whom they are 19 satisfied. The network shall include all public mental health 20 hospitals. To ensure unimpaired access to behavioral health 21 care services by Medicaid recipients, all contracts issued 22 pursuant to this paragraph shall require 80 percent of the 23 capitation paid to the managed care plan, including health 24 maintenance organizations, to be expended for the provision of 25 behavioral health care services. In the event the managed care 26 plan expends less than 80 percent of the capitation paid 27 pursuant to this paragraph for the provision of behavioral 28 health care services, the difference shall be returned to the 29 agency. The agency shall provide the managed care plan with a 30 certification letter indicating the amount of capitation paid 31 during each calendar year for the provision of behavioral 5 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 health care services pursuant to this section. The agency may 2 reimburse for substance abuse treatment services on a 3 fee-for-service basis until the agency finds that adequate 4 funds are available for capitated, prepaid arrangements. 5 1. By January 1, 2001, the agency shall modify the 6 contracts with the entities providing comprehensive inpatient 7 and outpatient mental health care services to Medicaid 8 recipients in Hillsborough, Highlands, Hardee, Manatee, and 9 Polk Counties, to include substance abuse treatment services. 10 2. By July 1, 2003, the agency and the Department of 11 Children and Family Services shall execute a written agreement 12 that requires collaboration and joint development of all 13 policy, budgets, procurement documents, contracts, and 14 monitoring plans that have an impact on the state and Medicaid 15 community mental health and targeted case management programs. 16 3. Except as provided in subparagraph 8., by July 1, 17 2006, the agency and the Department of Children and Family 18 Services shall contract with managed care entities in each 19 AHCA area except area 6 or arrange to provide comprehensive 20 inpatient and outpatient mental health and substance abuse 21 services through capitated prepaid arrangements to all 22 Medicaid recipients who are eligible to participate in such 23 plans under federal law and regulation. In AHCA areas where 24 eligible individuals number less than 150,000, the agency 25 shall contract with a single managed care plan to provide 26 comprehensive behavioral health services to all recipients who 27 are not enrolled in a Medicaid health maintenance 28 organization. The agency may contract with more than one 29 comprehensive behavioral health provider to provide care to 30 recipients who are not enrolled in a Medicaid health 31 maintenance organization in AHCA areas where the eligible 6 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 population exceeds 150,000. Contracts for comprehensive 2 behavioral health providers awarded pursuant to this section 3 shall be competitively procured. Both for-profit and 4 not-for-profit corporations shall be eligible to compete. 5 Managed care plans contracting with the agency under 6 subsection (3) shall provide and receive payment for the same 7 comprehensive behavioral health benefits as provided in AHCA 8 rules, including handbooks incorporated by reference. 9 4. By October 1, 2003, the agency and the department 10 shall submit a plan to the Governor, the President of the 11 Senate, and the Speaker of the House of Representatives which 12 provides for the full implementation of capitated prepaid 13 behavioral health care in all areas of the state. 14 a. Implementation shall begin in 2003 in those AHCA 15 areas of the state where the agency is able to establish 16 sufficient capitation rates. 17 b. If the agency determines that the proposed 18 capitation rate in any area is insufficient to provide 19 appropriate services, the agency may adjust the capitation 20 rate to ensure that care will be available. The agency and the 21 department may use existing general revenue to address any 22 additional required match but may not over-obligate existing 23 funds on an annualized basis. 24 c. Subject to any limitations provided for in the 25 General Appropriations Act, the agency, in compliance with 26 appropriate federal authorization, shall develop policies and 27 procedures that allow for certification of local and state 28 funds. 29 5. Children residing in a statewide inpatient 30 psychiatric program, or in a Department of Juvenile Justice or 31 a Department of Children and Family Services residential 7 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 program approved as a Medicaid behavioral health overlay 2 services provider shall not be included in a behavioral health 3 care prepaid health plan or any other Medicaid managed care 4 plan pursuant to this paragraph. 5 6. In converting to a prepaid system of delivery, the 6 agency shall in its procurement document require an entity 7 providing only comprehensive behavioral health care services 8 to prevent the displacement of indigent care patients by 9 enrollees in the Medicaid prepaid health plan providing 10 behavioral health care services from facilities receiving 11 state funding to provide indigent behavioral health care, to 12 facilities licensed under chapter 395 which do not receive 13 state funding for indigent behavioral health care, or 14 reimburse the unsubsidized facility for the cost of behavioral 15 health care provided to the displaced indigent care patient. 16 7. Traditional community mental health providers under 17 contract with the Department of Children and Family Services 18 pursuant to part IV of chapter 394, child welfare providers 19 under contract with the Department of Children and Family 20 Services in areas 1 and 6, and inpatient mental health 21 providers licensed pursuant to chapter 395 must be offered an 22 opportunity to accept or decline a contract to participate in 23 any provider network for prepaid behavioral health services. 24 8. For fiscal year 2004-2005, all Medicaid eligible 25 children, except children in areas 1 and 6, whose cases are 26 open for child welfare services in the HomeSafeNet system, 27 shall be enrolled in MediPass or in Medicaid fee-for-service 28 and all their behavioral health care services including 29 inpatient, outpatient psychiatric, community mental health, 30 and case management shall be reimbursed on a fee-for-service 31 basis. Beginning July 1, 2005, such children, who are open for 8 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 child welfare services in the HomeSafeNet system, shall 2 receive their behavioral health care services through a 3 specialty prepaid plan operated by community-based lead 4 agencies either through a single agency or formal agreements 5 among several agencies. The specialty prepaid plan must result 6 in savings to the state comparable to savings achieved in 7 other Medicaid managed care and prepaid programs. Such plan 8 must provide mechanisms to maximize state and local revenues. 9 The specialty prepaid plan shall be developed by the agency 10 and the Department of Children and Family Services. The agency 11 is authorized to seek any federal waivers to implement this 12 initiative. 13 (c) A federally qualified health center or an entity 14 owned by one or more federally qualified health centers or an 15 entity owned by other migrant and community health centers 16 receiving non-Medicaid financial support from the Federal 17 Government to provide health care services on a prepaid or 18 fixed-sum basis to recipients. Such prepaid health care 19 services entity must be licensed under parts I and III of 20 chapter 641, but shall be prohibited from serving Medicaid 21 recipients on a prepaid basis, until such licensure has been 22 obtained. However, such an entity is exempt from s. 641.225 if 23 the entity meets the requirements specified in subsections 24 (17) and (18). 25 (d) A provider service network may be reimbursed on a 26 fee-for-service or prepaid basis. A provider service network 27 which is reimbursed by the agency on a prepaid basis shall be 28 exempt from parts I and III of chapter 641, but must meet 29 appropriate financial reserve, quality assurance, and patient 30 rights requirements as established by the agency. The agency 31 shall award contracts on a competitive bid basis and shall 9 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 select bidders based upon price and quality of care. Medicaid 2 recipients assigned to a demonstration project shall be chosen 3 equally from those who would otherwise have been assigned to 4 prepaid plans and MediPass. The agency is authorized to seek 5 federal Medicaid waivers as necessary to implement the 6 provisions of this section. Any contract previously awarded to 7 a provider service network operated by a hospital pursuant to 8 this subsection shall remain in effect for a period of 3 years 9 following the current contract-expiration date, regardless of 10 any contractual provisions to the contrary. A provider service 11 network is a network established or organized and operated by 12 a health care provider, or group of affiliated health care 13 providers, which provides a substantial proportion of the 14 health care items and services under a contract directly 15 through the provider or affiliated group of providers and may 16 make arrangements with physicians or other health care 17 professionals, health care institutions, or any combination of 18 such individuals or institutions to assume all or part of the 19 financial risk on a prospective basis for the provision of 20 basic health services by the physicians, by other health 21 professionals, or through the institutions. The health care 22 providers must have a controlling interest in the governing 23 body of the provider service network organization. 24 (e) An entity that provides only comprehensive 25 behavioral health care services to certain Medicaid recipients 26 through an administrative services organization agreement. 27 Such an entity must possess the clinical systems and 28 operational competence to provide comprehensive health care to 29 Medicaid recipients. As used in this paragraph, the term 30 "comprehensive behavioral health care services" means covered 31 mental health and substance abuse treatment services that are 10 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 available to Medicaid recipients. Any contract awarded under 2 this paragraph must be competitively procured. The agency must 3 ensure that Medicaid recipients have available the choice of 4 at least two managed care plans for their behavioral health 5 care services. 6 (f) An entity that provides in-home physician services 7 to test the cost-effectiveness of enhanced home-based medical 8 care to Medicaid recipients with degenerative neurological 9 diseases and other diseases or disabling conditions associated 10 with high costs to Medicaid. The program shall be designed to 11 serve very disabled persons and to reduce Medicaid reimbursed 12 costs for inpatient, outpatient, and emergency department 13 services. The agency shall contract with vendors on a 14 risk-sharing basis. 15 (g) Children's provider networks that provide care 16 coordination and care management for Medicaid-eligible 17 pediatric patients, primary care, authorization of specialty 18 care, and other urgent and emergency care through organized 19 providers designed to service Medicaid eligibles under age 18 20 and pediatric emergency departments' diversion programs. The 21 networks shall provide after-hour operations, including 22 evening and weekend hours, to promote, when appropriate, the 23 use of the children's networks rather than hospital emergency 24 departments. 25 (h) An entity authorized in s. 430.205 to contract 26 with the agency and the Department of Elderly Affairs to 27 provide health care and social services on a prepaid or 28 fixed-sum basis to elderly recipients. Such prepaid health 29 care services entities are exempt from the provisions of part 30 I of chapter 641 for the first 3 years of operation. An entity 31 recognized under this paragraph that demonstrates to the 11 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 satisfaction of the Office of Insurance Regulation that it is 2 backed by the full faith and credit of one or more counties in 3 which it operates may be exempted from s. 641.225. 4 (i) A Children's Medical Services Network, as defined 5 in s. 391.021. 6 (5) By December 1, 2005, the Agency for Health Care 7 Administration, in partnership with the Department of Elderly 8 Affairs, shall create an integrated, fixed-payment delivery 9 system for Medicaid recipients who are 60 years of age or 10 older. The Agency for Health Care Administration shall 11 implement the integrated system initially on a pilot basis in 12 two areas of the state. In one of the areas enrollment shall 13 be on a voluntary basis. The program must transfer all 14 Medicaid services for eligible elderly individuals who choose 15 to participate into an integrated-care management model 16 designed to serve Medicaid recipients in the community. The 17 program must combine all funding for Medicaid services 18 provided to individuals 60 years of age or older into the 19 integrated system, including funds for Medicaid home and 20 community-based waiver services; all Medicaid services 21 authorized in ss. 409.905 and 409.906, excluding funds for 22 Medicaid nursing home services unless the agency is able to 23 demonstrate how the integration of the funds will improve 24 coordinated care for these services in a less costly manner; 25 and Medicare coinsurance and deductibles for persons dually 26 eligible for Medicaid and Medicare as prescribed in s. 27 409.908(13). 28 (a) Individuals who are 60 years of age or older and 29 enrolled in the the developmental disabilities waiver program, 30 the family and supported-living waiver program, the project 31 AIDS care waiver program, the traumatic brain injury and 12 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 spinal cord injury waiver program, the consumer-directed care 2 waiver program, and the program of all-inclusive care for the 3 elderly program, and residents of institutional care 4 facilities for the developmentally disabled, must be excluded 5 from the integrated system. 6 (b) The program must use a competitive-procurement 7 process to select entities to operate the integrated system. 8 Entities eligible to submit bids include managed care 9 organizations licensed under chapter 641, including entities 10 eligible to participate in the nursing home diversion program, 11 other qualified providers as defined in s. 430.703(7), 12 community care for the elderly lead agencies, and other 13 state-certified community service networks that meet 14 comparable standards as defined by the agency, in consultation 15 with the Department of Elderly Affairs and the Office of 16 Insurance Regulation, to be financially solvent and able to 17 take on financial risk for managed care. Community service 18 networks that are certified pursuant to the comparable 19 standards defined by the agency are not required to be 20 licensed under chapter 641. 21 (c) The agency must ensure that the 22 capitation-rate-setting methodology for the integrated system 23 is actuarially sound and reflects the intent to provide 24 quality care in the least-restrictive setting. The agency must 25 also require integrated-system providers to develop a 26 credentialing system for service providers and to contract 27 with all Gold Seal nursing homes, where feasible, and exclude, 28 where feasible, chronically poor-performing facilities and 29 providers as defined by the agency. The integrated system must 30 provide that if the recipient resides in a noncontracted 31 residential facility licensed under chapter 400 at the time 13 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 the integrated system is initiated, the recipient must be 2 permitted to continue to reside in the noncontracted facility 3 as long as the recipient desires. The integrated system must 4 also provide that, in the absence of a contract between the 5 integrated-system provider and the residential facility 6 licensed under chapter 400, current Medicaid rates must 7 prevail. The agency and the Department of Elderly Affairs must 8 jointly develop procedures to manage the services provided 9 through the integrated system in order to ensure quality and 10 recipient choice. 11 (d) Within 24 months after implementation, the Office 12 of Program Policy Analysis and Government Accountability, in 13 consultation with the Auditor General, shall comprehensively 14 evaluate the pilot project for the integrated, fixed-payment 15 delivery system for Medicaid recipients who are 60 years of 16 age or older. The evaluation must include assessments of cost 17 savings; consumer education, choice, and access to services; 18 coordination of care; and quality of care. The evaluation must 19 describe administrative or legal barriers to the 20 implementation and operation of the pilot program and include 21 recommendations regarding statewide expansion of the pilot 22 program. The office shall submit an evaluation report to the 23 Governor, the President of the Senate, and the Speaker of the 24 House of Representatives no later than June 30, 2008. 25 (e) The agency may seek federal waivers and adopt 26 rules as necessary to administer the integrated system. The 27 agency must receive specific authorization from the 28 Legislature prior to implementing the waiver for the 29 integrated system. By October 1, 2003, the agency and the 30 department shall, to the extent feasible, develop a plan for 31 implementing new Medicaid procedure codes for emergency and 14 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 crisis care, supportive residential services, and other 2 services designed to maximize the use of Medicaid funds for 3 Medicaid-eligible recipients. The agency shall include in the 4 agreement developed pursuant to subsection (4) a provision 5 that ensures that the match requirements for these new 6 procedure codes are met by certifying eligible general revenue 7 or local funds that are currently expended on these services 8 by the department with contracted alcohol, drug abuse, and 9 mental health providers. The plan must describe specific 10 procedure codes to be implemented, a projection of the number 11 of procedures to be delivered during fiscal year 2003-2004, 12 and a financial analysis that describes the certified match 13 procedures, and accountability mechanisms, projects the 14 earnings associated with these procedures, and describes the 15 sources of state match. This plan may not be implemented in 16 any part until approved by the Legislative Budget Commission. 17 If such approval has not occurred by December 31, 2003, the 18 plan shall be submitted for consideration by the 2004 19 Legislature. 20 (6) The agency may contract with any public or private 21 entity otherwise authorized by this section on a prepaid or 22 fixed-sum basis for the provision of health care services to 23 recipients. An entity may provide prepaid services to 24 recipients, either directly or through arrangements with other 25 entities, if each entity involved in providing services: 26 (a) Is organized primarily for the purpose of 27 providing health care or other services of the type regularly 28 offered to Medicaid recipients; 29 (b) Ensures that services meet the standards set by 30 the agency for quality, appropriateness, and timeliness; 31 (c) Makes provisions satisfactory to the agency for 15 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 insolvency protection and ensures that neither enrolled 2 Medicaid recipients nor the agency will be liable for the 3 debts of the entity; 4 (d) Submits to the agency, if a private entity, a 5 financial plan that the agency finds to be fiscally sound and 6 that provides for working capital in the form of cash or 7 equivalent liquid assets excluding revenues from Medicaid 8 premium payments equal to at least the first 3 months of 9 operating expenses or $200,000, whichever is greater; 10 (e) Furnishes evidence satisfactory to the agency of 11 adequate liability insurance coverage or an adequate plan of 12 self-insurance to respond to claims for injuries arising out 13 of the furnishing of health care; 14 (f) Provides, through contract or otherwise, for 15 periodic review of its medical facilities and services, as 16 required by the agency; and 17 (g) Provides organizational, operational, financial, 18 and other information required by the agency. 19 (7) The agency may contract on a prepaid or fixed-sum 20 basis with any health insurer that: 21 (a) Pays for health care services provided to enrolled 22 Medicaid recipients in exchange for a premium payment paid by 23 the agency; 24 (b) Assumes the underwriting risk; and 25 (c) Is organized and licensed under applicable 26 provisions of the Florida Insurance Code and is currently in 27 good standing with the Office of Insurance Regulation. 28 (8) The agency may contract on a prepaid or fixed-sum 29 basis with an exclusive provider organization to provide 30 health care services to Medicaid recipients provided that the 31 exclusive provider organization meets applicable managed care 16 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 plan requirements in this section, ss. 409.9122, 409.9123, 2 409.9128, and 627.6472, and other applicable provisions of 3 law. 4 (9) The Agency for Health Care Administration may 5 provide cost-effective purchasing of chiropractic services on 6 a fee-for-service basis to Medicaid recipients through 7 arrangements with a statewide chiropractic preferred provider 8 organization incorporated in this state as a not-for-profit 9 corporation. The agency shall ensure that the benefit limits 10 and prior authorization requirements in the current Medicaid 11 program shall apply to the services provided by the 12 chiropractic preferred provider organization. 13 (10) The agency shall not contract on a prepaid or 14 fixed-sum basis for Medicaid services with an entity which 15 knows or reasonably should know that any officer, director, 16 agent, managing employee, or owner of stock or beneficial 17 interest in excess of 5 percent common or preferred stock, or 18 the entity itself, has been found guilty of, regardless of 19 adjudication, or entered a plea of nolo contendere, or guilty, 20 to: 21 (a) Fraud; 22 (b) Violation of federal or state antitrust statutes, 23 including those proscribing price fixing between competitors 24 and the allocation of customers among competitors; 25 (c) Commission of a felony involving embezzlement, 26 theft, forgery, income tax evasion, bribery, falsification or 27 destruction of records, making false statements, receiving 28 stolen property, making false claims, or obstruction of 29 justice; or 30 (d) Any crime in any jurisdiction which directly 31 relates to the provision of health services on a prepaid or 17 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 fixed-sum basis. 2 (11) The agency, after notifying the Legislature, may 3 apply for waivers of applicable federal laws and regulations 4 as necessary to implement more appropriate systems of health 5 care for Medicaid recipients and reduce the cost of the 6 Medicaid program to the state and federal governments and 7 shall implement such programs, after legislative approval, 8 within a reasonable period of time after federal approval. 9 These programs must be designed primarily to reduce the need 10 for inpatient care, custodial care and other long-term or 11 institutional care, and other high-cost services. 12 (a) Prior to seeking legislative approval of such a 13 waiver as authorized by this subsection, the agency shall 14 provide notice and an opportunity for public comment. Notice 15 shall be provided to all persons who have made requests of the 16 agency for advance notice and shall be published in the 17 Florida Administrative Weekly not less than 28 days prior to 18 the intended action. 19 (b) Notwithstanding s. 216.292, funds that are 20 appropriated to the Department of Elderly Affairs for the 21 Assisted Living for the Elderly Medicaid waiver and are not 22 expended shall be transferred to the agency to fund 23 Medicaid-reimbursed nursing home care. 24 (12) The agency shall establish a postpayment 25 utilization control program designed to identify recipients 26 who may inappropriately overuse or underuse Medicaid services 27 and shall provide methods to correct such misuse. 28 (13) The agency shall develop and provide coordinated 29 systems of care for Medicaid recipients and may contract with 30 public or private entities to develop and administer such 31 systems of care among public and private health care providers 18 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 in a given geographic area. 2 (14)(a) The agency shall operate or contract for the 3 operation of utilization management and incentive systems 4 designed to encourage cost-effective use services. 5 (b) The agency shall develop a procedure for 6 determining whether health care providers and service vendors 7 can provide the Medicaid program using a business case that 8 demonstrates whether a particular good or service can offset 9 the cost of providing the good or service in an alternative 10 setting or through other means and therefore should receive a 11 higher reimbursement. The business case must include, but need 12 not be limited to: 13 1. A detailed description of the good or service to be 14 provided, a description and analysis of the agency's current 15 performance of the service, and a rationale documenting how 16 providing the service in an alternative setting would be in 17 the best interest of the state, the agency, and its clients. 18 2. A cost-benefit analysis documenting the estimated 19 specific direct and indirect costs, savings, performance 20 improvements, risks, and qualitative and quantitative benefits 21 involved in or resulting from providing the service. The 22 cost-benefit analysis must include a detailed plan and 23 timeline identifying all actions that must be implemented to 24 realize expected benefits. The Secretary of Health Care 25 Administration shall verify that all costs, savings, and 26 benefits are valid and achievable. 27 (c) If the agency determines that the increased 28 reimbursement is cost-effective, the agency shall recommend a 29 change in the reimbursement schedule for that particular good 30 or service. If, within 12 months after implementing any rate 31 change under this procedure, the agency determines that costs 19 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 were not offset by the increased reimbursement schedule, the 2 agency may revert to the former reimbursement schedule for the 3 particular good or service. 4 (15)(a) The agency shall operate the Comprehensive 5 Assessment and Review for Long-Term Care Services (CARES) 6 nursing facility preadmission screening program to ensure that 7 Medicaid payment for nursing facility care is made only for 8 individuals whose conditions require such care and to ensure 9 that long-term care services are provided in the setting most 10 appropriate to the needs of the person and in the most 11 economical manner possible. The CARES program shall also 12 ensure that individuals participating in Medicaid home and 13 community-based waiver programs meet criteria for those 14 programs, consistent with approved federal waivers. 15 (b) The agency shall operate the CARES program through 16 an interagency agreement with the Department of Elderly 17 Affairs. The agency, in consultation with the Department of 18 Elderly Affairs, may contract for any function or activity of 19 the CARES program, including any function or activity required 20 by 42 C.F.R. part 483.20, relating to preadmission screening 21 and resident review. 22 (c) Prior to making payment for nursing facility 23 services for a Medicaid recipient, the agency must verify that 24 the nursing facility preadmission screening program has 25 determined that the individual requires nursing facility care 26 and that the individual cannot be safely served in 27 community-based programs. The nursing facility preadmission 28 screening program shall refer a Medicaid recipient to a 29 community-based program if the individual could be safely 30 served at a lower cost and the recipient chooses to 31 participate in such program. For individuals whose nursing 20 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 home stay is initially funded by Medicare and Medicare 2 coverage is being terminated for lack of progress towards 3 rehabilitation, CARES staff shall consult with the person 4 making the determination of progress toward rehabilitation to 5 ensure that the recipient is not being inappropriately 6 disqualified from Medicare coverage. If, in their professional 7 judgment, CARES staff believes that a Medicare beneficiary is 8 still making progress toward rehabilitation, they may assist 9 the Medicare beneficiary with an appeal of the 10 disqualification from Medicare coverage. The use of CARES 11 teams to review Medicare denials for coverage under this 12 section is authorized only if it is determined that such 13 reviews qualify for federal matching funds through Medicaid. 14 The agency shall seek or amend federal waivers as necessary to 15 implement this section. 16 (d) For the purpose of initiating immediate 17 prescreening and diversion assistance for individuals residing 18 in nursing homes and in order to make families aware of 19 alternative long-term care resources so that they may choose a 20 more cost-effective setting for long-term placement, CARES 21 staff shall conduct an assessment and review of a sample of 22 individuals whose nursing home stay is expected to exceed 20 23 days, regardless of the initial funding source for the nursing 24 home placement. CARES staff shall provide counseling and 25 referral services to these individuals regarding choosing 26 appropriate long-term care alternatives. This paragraph does 27 not apply to continuing care facilities licensed under chapter 28 651 or to retirement communities that provide a combination of 29 nursing home, independent living, and other long-term care 30 services. 31 (e) By January 15 of each year, the agency shall 21 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 submit a report to the Legislature and the Office of 2 Long-Term-Care Policy describing the operations of the CARES 3 program. The report must describe: 4 1. Rate of diversion to community alternative 5 programs; 6 2. CARES program staffing needs to achieve additional 7 diversions; 8 3. Reasons the program is unable to place individuals 9 in less restrictive settings when such individuals desired 10 such services and could have been served in such settings; 11 4. Barriers to appropriate placement, including 12 barriers due to policies or operations of other agencies or 13 state-funded programs; and 14 5. Statutory changes necessary to ensure that 15 individuals in need of long-term care services receive care in 16 the least restrictive environment. 17 (f) The Department of Elderly Affairs shall track 18 individuals over time who are assessed under the CARES program 19 and who are diverted from nursing home placement. By January 20 15 of each year, the department shall submit to the 21 Legislature and the Office of Long-Term-Care Policy a 22 longitudinal study of the individuals who are diverted from 23 nursing home placement. The study must include: 24 1. The demographic characteristics of the individuals 25 assessed and diverted from nursing home placement, including, 26 but not limited to, age, race, gender, frailty, caregiver 27 status, living arrangements, and geographic location; 28 2. A summary of community services provided to 29 individuals for 1 year after assessment and diversion; 30 3. A summary of inpatient hospital admissions for 31 individuals who have been diverted; and 22 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 4. A summary of the length of time between diversion 2 and subsequent entry into a nursing home or death. 3 (g) By July 1, 2005, the department and the Agency for 4 Health Care Administration shall report to the President of 5 the Senate and the Speaker of the House of Representatives 6 regarding the impact to the state of modifying level-of-care 7 criteria to eliminate the Intermediate II level of care. 8 (16)(a) The agency shall identify health care 9 utilization and price patterns within the Medicaid program 10 which are not cost-effective or medically appropriate and 11 assess the effectiveness of new or alternate methods of 12 providing and monitoring service, and may implement such 13 methods as it considers appropriate. Such methods may include 14 disease management initiatives, an integrated and systematic 15 approach for managing the health care needs of recipients who 16 are at risk of or diagnosed with a specific disease by using 17 best practices, prevention strategies, clinical-practice 18 improvement, clinical interventions and protocols, outcomes 19 research, information technology, and other tools and 20 resources to reduce overall costs and improve measurable 21 outcomes. 22 (b) The responsibility of the agency under this 23 subsection shall include the development of capabilities to 24 identify actual and optimal practice patterns; patient and 25 provider educational initiatives; methods for determining 26 patient compliance with prescribed treatments; fraud, waste, 27 and abuse prevention and detection programs; and beneficiary 28 case management programs. 29 1. The practice pattern identification program shall 30 evaluate practitioner prescribing patterns based on national 31 and regional practice guidelines, comparing practitioners to 23 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 their peer groups. The agency and its Drug Utilization Review 2 Board shall consult with the Department of Health and a panel 3 of practicing health care professionals consisting of the 4 following: the Speaker of the House of Representatives and the 5 President of the Senate shall each appoint three physicians 6 licensed under chapter 458 or chapter 459; and the Governor 7 shall appoint two pharmacists licensed under chapter 465 and 8 one dentist licensed under chapter 466 who is an oral surgeon. 9 Terms of the panel members shall expire at the discretion of 10 the appointing official. The panel shall begin its work by 11 August 1, 1999, regardless of the number of appointments made 12 by that date. The advisory panel shall be responsible for 13 evaluating treatment guidelines and recommending ways to 14 incorporate their use in the practice pattern identification 15 program. Practitioners who are prescribing inappropriately or 16 inefficiently, as determined by the agency, may have their 17 prescribing of certain drugs subject to prior authorization or 18 may be terminated from all participation in the Medicaid 19 program. 20 2. The agency shall also develop educational 21 interventions designed to promote the proper use of 22 medications by providers and beneficiaries. 23 3. The agency shall implement a pharmacy fraud, waste, 24 and abuse initiative that may include a surety bond or letter 25 of credit requirement for participating pharmacies, enhanced 26 provider auditing practices, the use of additional fraud and 27 abuse software, recipient management programs for 28 beneficiaries inappropriately using their benefits, and other 29 steps that will eliminate provider and recipient fraud, waste, 30 and abuse. The initiative shall address enforcement efforts to 31 reduce the number and use of counterfeit prescriptions. 24 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 4. By September 30, 2002, the agency shall contract 2 with an entity in the state to implement a wireless handheld 3 clinical pharmacology drug information database for 4 practitioners. The initiative shall be designed to enhance the 5 agency's efforts to reduce fraud, abuse, and errors in the 6 prescription drug benefit program and to otherwise further the 7 intent of this paragraph. 8 5. By April 1, 2006, the agency shall contract with an 9 entity to design a database of clinical utilization 10 information or electronic medical records for Medicaid 11 providers. This system must be web-based and allow providers 12 to review on a real-time basis the utilization of Medicaid 13 services, including, but not limited to, physician office 14 visits, inpatient and outpatient hospitalizations, laboratory 15 and pathology services, radiological and other imaging 16 services, dental care, and patterns of dispensing prescription 17 drugs in order to coordinate care and identify potential fraud 18 and abuse. 19 6.5. The agency may apply for any federal waivers 20 needed to administer implement this paragraph. 21 (17) An entity contracting on a prepaid or fixed-sum 22 basis shall, in addition to meeting any applicable statutory 23 surplus requirements, also maintain at all times in the form 24 of cash, investments that mature in less than 180 days 25 allowable as admitted assets by the Office of Insurance 26 Regulation, and restricted funds or deposits controlled by the 27 agency or the Office of Insurance Regulation, a surplus amount 28 equal to one-and-one-half times the entity's monthly Medicaid 29 prepaid revenues. As used in this subsection, the term 30 "surplus" means the entity's total assets minus total 31 liabilities. If an entity's surplus falls below an amount 25 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 equal to one-and-one-half times the entity's monthly Medicaid 2 prepaid revenues, the agency shall prohibit the entity from 3 engaging in marketing and preenrollment activities, shall 4 cease to process new enrollments, and shall not renew the 5 entity's contract until the required balance is achieved. The 6 requirements of this subsection do not apply: 7 (a) Where a public entity agrees to fund any deficit 8 incurred by the contracting entity; or 9 (b) Where the entity's performance and obligations are 10 guaranteed in writing by a guaranteeing organization which: 11 1. Has been in operation for at least 5 years and has 12 assets in excess of $50 million; or 13 2. Submits a written guarantee acceptable to the 14 agency which is irrevocable during the term of the contracting 15 entity's contract with the agency and, upon termination of the 16 contract, until the agency receives proof of satisfaction of 17 all outstanding obligations incurred under the contract. 18 (18)(a) The agency may require an entity contracting 19 on a prepaid or fixed-sum basis to establish a restricted 20 insolvency protection account with a federally guaranteed 21 financial institution licensed to do business in this state. 22 The entity shall deposit into that account 5 percent of the 23 capitation payments made by the agency each month until a 24 maximum total of 2 percent of the total current contract 25 amount is reached. The restricted insolvency protection 26 account may be drawn upon with the authorized signatures of 27 two persons designated by the entity and two representatives 28 of the agency. If the agency finds that the entity is 29 insolvent, the agency may draw upon the account solely with 30 the two authorized signatures of representatives of the 31 agency, and the funds may be disbursed to meet financial 26 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 obligations incurred by the entity under the prepaid contract. 2 If the contract is terminated, expired, or not continued, the 3 account balance must be released by the agency to the entity 4 upon receipt of proof of satisfaction of all outstanding 5 obligations incurred under this contract. 6 (b) The agency may waive the insolvency protection 7 account requirement in writing when evidence is on file with 8 the agency of adequate insolvency insurance and reinsurance 9 that will protect enrollees if the entity becomes unable to 10 meet its obligations. 11 (19) An entity that contracts with the agency on a 12 prepaid or fixed-sum basis for the provision of Medicaid 13 services shall reimburse any hospital or physician that is 14 outside the entity's authorized geographic service area as 15 specified in its contract with the agency, and that provides 16 services authorized by the entity to its members, at a rate 17 negotiated with the hospital or physician for the provision of 18 services or according to the lesser of the following: 19 (a) The usual and customary charges made to the 20 general public by the hospital or physician; or 21 (b) The Florida Medicaid reimbursement rate 22 established for the hospital or physician. 23 (20) When a merger or acquisition of a Medicaid 24 prepaid contractor has been approved by the Office of 25 Insurance Regulation pursuant to s. 628.4615, the agency shall 26 approve the assignment or transfer of the appropriate Medicaid 27 prepaid contract upon request of the surviving entity of the 28 merger or acquisition if the contractor and the other entity 29 have been in good standing with the agency for the most recent 30 12-month period, unless the agency determines that the 31 assignment or transfer would be detrimental to the Medicaid 27 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 recipients or the Medicaid program. To be in good standing, an 2 entity must not have failed accreditation or committed any 3 material violation of the requirements of s. 641.52 and must 4 meet the Medicaid contract requirements. For purposes of this 5 section, a merger or acquisition means a change in controlling 6 interest of an entity, including an asset or stock purchase. 7 (21) Any entity contracting with the agency pursuant 8 to this section to provide health care services to Medicaid 9 recipients is prohibited from engaging in any of the following 10 practices or activities: 11 (a) Practices that are discriminatory, including, but 12 not limited to, attempts to discourage participation on the 13 basis of actual or perceived health status. 14 (b) Activities that could mislead or confuse 15 recipients, or misrepresent the organization, its marketing 16 representatives, or the agency. Violations of this paragraph 17 include, but are not limited to: 18 1. False or misleading claims that marketing 19 representatives are employees or representatives of the state 20 or county, or of anyone other than the entity or the 21 organization by whom they are reimbursed. 22 2. False or misleading claims that the entity is 23 recommended or endorsed by any state or county agency, or by 24 any other organization which has not certified its endorsement 25 in writing to the entity. 26 3. False or misleading claims that the state or county 27 recommends that a Medicaid recipient enroll with an entity. 28 4. Claims that a Medicaid recipient will lose benefits 29 under the Medicaid program, or any other health or welfare 30 benefits to which the recipient is legally entitled, if the 31 recipient does not enroll with the entity. 28 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 (c) Granting or offering of any monetary or other 2 valuable consideration for enrollment, except as authorized by 3 subsection (24). 4 (d) Door-to-door solicitation of recipients who have 5 not contacted the entity or who have not invited the entity to 6 make a presentation. 7 (e) Solicitation of Medicaid recipients by marketing 8 representatives stationed in state offices unless approved and 9 supervised by the agency or its agent and approved by the 10 affected state agency when solicitation occurs in an office of 11 the state agency. The agency shall ensure that marketing 12 representatives stationed in state offices shall market their 13 managed care plans to Medicaid recipients only in designated 14 areas and in such a way as to not interfere with the 15 recipients' activities in the state office. 16 (f) Enrollment of Medicaid recipients. 17 (22) The agency may impose a fine for a violation of 18 this section or the contract with the agency by a person or 19 entity that is under contract with the agency. With respect to 20 any nonwillful violation, such fine shall not exceed $2,500 21 per violation. In no event shall such fine exceed an aggregate 22 amount of $10,000 for all nonwillful violations arising out of 23 the same action. With respect to any knowing and willful 24 violation of this section or the contract with the agency, the 25 agency may impose a fine upon the entity in an amount not to 26 exceed $20,000 for each such violation. In no event shall such 27 fine exceed an aggregate amount of $100,000 for all knowing 28 and willful violations arising out of the same action. 29 (23) A health maintenance organization or a person or 30 entity exempt from chapter 641 that is under contract with the 31 agency for the provision of health care services to Medicaid 29 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 recipients may not use or distribute marketing materials used 2 to solicit Medicaid recipients, unless such materials have 3 been approved by the agency. The provisions of this subsection 4 do not apply to general advertising and marketing materials 5 used by a health maintenance organization to solicit both 6 non-Medicaid subscribers and Medicaid recipients. 7 (24) Upon approval by the agency, health maintenance 8 organizations and persons or entities exempt from chapter 641 9 that are under contract with the agency for the provision of 10 health care services to Medicaid recipients may be permitted 11 within the capitation rate to provide additional health 12 benefits that the agency has found are of high quality, are 13 practicably available, provide reasonable value to the 14 recipient, and are provided at no additional cost to the 15 state. 16 (25) The agency shall utilize the statewide health 17 maintenance organization complaint hotline for the purpose of 18 investigating and resolving Medicaid and prepaid health plan 19 complaints, maintaining a record of complaints and confirmed 20 problems, and receiving disenrollment requests made by 21 recipients. 22 (26) The agency shall require the publication of the 23 health maintenance organization's and the prepaid health 24 plan's consumer services telephone numbers and the "800" 25 telephone number of the statewide health maintenance 26 organization complaint hotline on each Medicaid identification 27 card issued by a health maintenance organization or prepaid 28 health plan contracting with the agency to serve Medicaid 29 recipients and on each subscriber handbook issued to a 30 Medicaid recipient. 31 (27) The agency shall establish a health care quality 30 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 improvement system for those entities contracting with the 2 agency pursuant to this section, incorporating all the 3 standards and guidelines developed by the Medicaid Bureau of 4 the Health Care Financing Administration as a part of the 5 quality assurance reform initiative. The system shall include, 6 but need not be limited to, the following: 7 (a) Guidelines for internal quality assurance 8 programs, including standards for: 9 1. Written quality assurance program descriptions. 10 2. Responsibilities of the governing body for 11 monitoring, evaluating, and making improvements to care. 12 3. An active quality assurance committee. 13 4. Quality assurance program supervision. 14 5. Requiring the program to have adequate resources to 15 effectively carry out its specified activities. 16 6. Provider participation in the quality assurance 17 program. 18 7. Delegation of quality assurance program activities. 19 8. Credentialing and recredentialing. 20 9. Enrollee rights and responsibilities. 21 10. Availability and accessibility to services and 22 care. 23 11. Ambulatory care facilities. 24 12. Accessibility and availability of medical records, 25 as well as proper recordkeeping and process for record review. 26 13. Utilization review. 27 14. A continuity of care system. 28 15. Quality assurance program documentation. 29 16. Coordination of quality assurance activity with 30 other management activity. 31 17. Delivering care to pregnant women and infants; to 31 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 elderly and disabled recipients, especially those who are at 2 risk of institutional placement; to persons with developmental 3 disabilities; and to adults who have chronic, high-cost 4 medical conditions. 5 (b) Guidelines which require the entities to conduct 6 quality-of-care studies which: 7 1. Target specific conditions and specific health 8 service delivery issues for focused monitoring and evaluation. 9 2. Use clinical care standards or practice guidelines 10 to objectively evaluate the care the entity delivers or fails 11 to deliver for the targeted clinical conditions and health 12 services delivery issues. 13 3. Use quality indicators derived from the clinical 14 care standards or practice guidelines to screen and monitor 15 care and services delivered. 16 (c) Guidelines for external quality review of each 17 contractor which require: focused studies of patterns of care; 18 individual care review in specific situations; and followup 19 activities on previous pattern-of-care study findings and 20 individual-care-review findings. In designing the external 21 quality review function and determining how it is to operate 22 as part of the state's overall quality improvement system, the 23 agency shall construct its external quality review 24 organization and entity contracts to address each of the 25 following: 26 1. Delineating the role of the external quality review 27 organization. 28 2. Length of the external quality review organization 29 contract with the state. 30 3. Participation of the contracting entities in 31 designing external quality review organization review 32 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 activities. 2 4. Potential variation in the type of clinical 3 conditions and health services delivery issues to be studied 4 at each plan. 5 5. Determining the number of focused pattern-of-care 6 studies to be conducted for each plan. 7 6. Methods for implementing focused studies. 8 7. Individual care review. 9 8. Followup activities. 10 (28) In order to ensure that children receive health 11 care services for which an entity has already been 12 compensated, an entity contracting with the agency pursuant to 13 this section shall achieve an annual Early and Periodic 14 Screening, Diagnosis, and Treatment (EPSDT) Service screening 15 rate of at least 60 percent for those recipients continuously 16 enrolled for at least 8 months. The agency shall develop a 17 method by which the EPSDT screening rate shall be calculated. 18 For any entity which does not achieve the annual 60 percent 19 rate, the entity must submit a corrective action plan for the 20 agency's approval. If the entity does not meet the standard 21 established in the corrective action plan during the specified 22 timeframe, the agency is authorized to impose appropriate 23 contract sanctions. At least annually, the agency shall 24 publicly release the EPSDT Services screening rates of each 25 entity it has contracted with on a prepaid basis to serve 26 Medicaid recipients. 27 (29) The agency shall perform enrollments and 28 disenrollments for Medicaid recipients who are eligible for 29 MediPass or managed care plans. Notwithstanding the 30 prohibition contained in paragraph (21)(f), managed care plans 31 may perform preenrollments of Medicaid recipients under the 33 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 supervision of the agency or its agents. For the purposes of 2 this section, "preenrollment" means the provision of marketing 3 and educational materials to a Medicaid recipient and 4 assistance in completing the application forms, but shall not 5 include actual enrollment into a managed care plan. An 6 application for enrollment shall not be deemed complete until 7 the agency or its agent verifies that the recipient made an 8 informed, voluntary choice. The agency, in cooperation with 9 the Department of Children and Family Services, may test new 10 marketing initiatives to inform Medicaid recipients about 11 their managed care options at selected sites. The agency shall 12 report to the Legislature on the effectiveness of such 13 initiatives. The agency may contract with a third party to 14 perform managed care plan and MediPass enrollment and 15 disenrollment services for Medicaid recipients and is 16 authorized to adopt rules to implement such services. The 17 agency may adjust the capitation rate only to cover the costs 18 of a third-party enrollment and disenrollment contract, and 19 for agency supervision and management of the managed care plan 20 enrollment and disenrollment contract. 21 (30) Any lists of providers made available to Medicaid 22 recipients, MediPass enrollees, or managed care plan enrollees 23 shall be arranged alphabetically showing the provider's name 24 and specialty and, separately, by specialty in alphabetical 25 order. 26 (31) The agency shall establish an enhanced managed 27 care quality assurance oversight function, to include at least 28 the following components: 29 (a) At least quarterly analysis and followup, 30 including sanctions as appropriate, of managed care 31 participant utilization of services. 34 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 (b) At least quarterly analysis and followup, 2 including sanctions as appropriate, of quality findings of the 3 Medicaid peer review organization and other external quality 4 assurance programs. 5 (c) At least quarterly analysis and followup, 6 including sanctions as appropriate, of the fiscal viability of 7 managed care plans. 8 (d) At least quarterly analysis and followup, 9 including sanctions as appropriate, of managed care 10 participant satisfaction and disenrollment surveys. 11 (e) The agency shall conduct regular and ongoing 12 Medicaid recipient satisfaction surveys. 13 14 The analyses and followup activities conducted by the agency 15 under its enhanced managed care quality assurance oversight 16 function shall not duplicate the activities of accreditation 17 reviewers for entities regulated under part III of chapter 18 641, but may include a review of the finding of such 19 reviewers. 20 (32) Each managed care plan that is under contract 21 with the agency to provide health care services to Medicaid 22 recipients shall annually conduct a background check with the 23 Florida Department of Law Enforcement of all persons with 24 ownership interest of 5 percent or more or executive 25 management responsibility for the managed care plan and shall 26 submit to the agency information concerning any such person 27 who has been found guilty of, regardless of adjudication, or 28 has entered a plea of nolo contendere or guilty to, any of the 29 offenses listed in s. 435.03. 30 (33) The agency shall, by rule, develop a process 31 whereby a Medicaid managed care plan enrollee who wishes to 35 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 enter hospice care may be disenrolled from the managed care 2 plan within 24 hours after contacting the agency regarding 3 such request. The agency rule shall include a methodology for 4 the agency to recoup managed care plan payments on a pro rata 5 basis if payment has been made for the enrollment month when 6 disenrollment occurs. 7 (34) The agency and entities that which contract with 8 the agency to provide health care services to Medicaid 9 recipients under this section or ss. 409.91211 and s. 409.9122 10 must comply with the provisions of s. 641.513 in providing 11 emergency services and care to Medicaid recipients and 12 MediPass recipients. Where feasible, safe, and cost-effective, 13 the agency shall encourage hospitals, emergency medical 14 services providers, and other public and private health care 15 providers to work together in their local communities to enter 16 into agreements or arrangements to ensure access to 17 alternatives to emergency services and care for those Medicaid 18 recipients who need nonemergent care. The agency shall 19 coordinate with hospitals, emergency medical services 20 providers, private health plans, capitated managed care 21 networks as established in s. 409.91211, and other public and 22 private health care providers to implement the provisions of 23 ss. 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to 24 develop and implement emergency department diversion programs 25 for Medicaid recipients. 26 (35) All entities providing health care services to 27 Medicaid recipients shall make available, and encourage all 28 pregnant women and mothers with infants to receive, and 29 provide documentation in the medical records to reflect, the 30 following: 31 (a) Healthy Start prenatal or infant screening. 36 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 (b) Healthy Start care coordination, when screening or 2 other factors indicate need. 3 (c) Healthy Start enhanced services in accordance with 4 the prenatal or infant screening results. 5 (d) Immunizations in accordance with recommendations 6 of the Advisory Committee on Immunization Practices of the 7 United States Public Health Service and the American Academy 8 of Pediatrics, as appropriate. 9 (e) Counseling and services for family planning to all 10 women and their partners. 11 (f) A scheduled postpartum visit for the purpose of 12 voluntary family planning, to include discussion of all 13 methods of contraception, as appropriate. 14 (g) Referral to the Special Supplemental Nutrition 15 Program for Women, Infants, and Children (WIC). 16 (36) Any entity that provides Medicaid prepaid health 17 plan services shall ensure the appropriate coordination of 18 health care services with an assisted living facility in cases 19 where a Medicaid recipient is both a member of the entity's 20 prepaid health plan and a resident of the assisted living 21 facility. If the entity is at risk for Medicaid targeted case 22 management and behavioral health services, the entity shall 23 inform the assisted living facility of the procedures to 24 follow should an emergent condition arise. 25 (37) The agency may seek and implement federal waivers 26 necessary to provide for cost-effective purchasing of home 27 health services, private duty nursing services, 28 transportation, independent laboratory services, and durable 29 medical equipment and supplies through competitive bidding 30 pursuant to s. 287.057. The agency may request appropriate 31 waivers from the federal Health Care Financing Administration 37 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 in order to competitively bid such services. The agency may 2 exclude providers not selected through the bidding process 3 from the Medicaid provider network. 4 (38) The agency shall enter into agreements with 5 not-for-profit organizations based in this state for the 6 purpose of providing vision screening. 7 (39)(a) The agency shall implement a Medicaid 8 prescribed-drug spending-control program that includes the 9 following components: 10 1. Medicaid prescribed-drug coverage for brand-name 11 drugs for adult Medicaid recipients is limited to the 12 dispensing of four brand-name drugs per month per recipient. 13 Children are exempt from this restriction. Antiretroviral 14 agents are excluded from this limitation. No requirements for 15 prior authorization or other restrictions on medications used 16 to treat mental illnesses such as schizophrenia, severe 17 depression, or bipolar disorder may be imposed on Medicaid 18 recipients. Medications that will be available without 19 restriction for persons with mental illnesses include atypical 20 antipsychotic medications, conventional antipsychotic 21 medications, selective serotonin reuptake inhibitors, and 22 other medications used for the treatment of serious mental 23 illnesses. The agency shall also limit the amount of a 24 prescribed drug dispensed to no more than a 34-day supply. The 25 agency shall continue to provide unlimited generic drugs, 26 contraceptive drugs and items, and diabetic supplies. Although 27 a drug may be included on the preferred drug formulary, it 28 would not be exempt from the four-brand limit. The agency may 29 authorize exceptions to the brand-name-drug restriction based 30 upon the treatment needs of the patients, only when such 31 exceptions are based on prior consultation provided by the 38 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 agency or an agency contractor, but the agency must establish 2 procedures to ensure that: 3 a. There will be a response to a request for prior 4 consultation by telephone or other telecommunication device 5 within 24 hours after receipt of a request for prior 6 consultation; 7 b. A 72-hour supply of the drug prescribed will be 8 provided in an emergency or when the agency does not provide a 9 response within 24 hours as required by sub-subparagraph a.; 10 and 11 c. Except for the exception for nursing home residents 12 and other institutionalized adults and except for drugs on the 13 restricted formulary for which prior authorization may be 14 sought by an institutional or community pharmacy, prior 15 authorization for an exception to the brand-name-drug 16 restriction is sought by the prescriber and not by the 17 pharmacy. When prior authorization is granted for a patient in 18 an institutional setting beyond the brand-name-drug 19 restriction, such approval is authorized for 12 months and 20 monthly prior authorization is not required for that patient. 21 2. Reimbursement to pharmacies for Medicaid prescribed 22 drugs shall be set at the lesser of: the average wholesale 23 price (AWP) minus 15.4 percent, the wholesaler acquisition 24 cost (WAC) plus 5.75 percent, the federal upper limit (FUL), 25 the state maximum allowable cost (SMAC), or the usual and 26 customary (UAC) charge billed by the provider. 27 3. The agency shall develop and implement a process 28 for managing the drug therapies of Medicaid recipients who are 29 using significant numbers of prescribed drugs each month. The 30 management process may include, but is not limited to, 31 comprehensive, physician-directed medical-record reviews, 39 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 claims analyses, and case evaluations to determine the medical 2 necessity and appropriateness of a patient's treatment plan 3 and drug therapies. The agency may contract with a private 4 organization to provide drug-program-management services. The 5 Medicaid drug benefit management program shall include 6 initiatives to manage drug therapies for HIV/AIDS patients, 7 patients using 20 or more unique prescriptions in a 180-day 8 period, and the top 1,000 patients in annual spending. The 9 agency shall enroll any Medicaid recipient in the drug benefit 10 management program if he or she meets the specifications of 11 this provision and is not enrolled in a Medicaid health 12 maintenance organization. 13 4. The agency may limit the size of its pharmacy 14 network based on need, competitive bidding, price 15 negotiations, credentialing, or similar criteria. The agency 16 shall give special consideration to rural areas in determining 17 the size and location of pharmacies included in the Medicaid 18 pharmacy network. A pharmacy credentialing process may include 19 criteria such as a pharmacy's full-service status, location, 20 size, patient educational programs, patient consultation, 21 disease-management services, and other characteristics. The 22 agency may impose a moratorium on Medicaid pharmacy enrollment 23 when it is determined that it has a sufficient number of 24 Medicaid-participating providers. The agency must allow 25 dispensing practitioners to participate as a part of the 26 Medicaid pharmacy network regardless of the practitioner's 27 proximity to any other entity that is dispensing prescription 28 drugs under the Medicaid program. A dispensing practitioner 29 must meet all credentialing requirements applicable to his or 30 her practice, as determined by the agency. 31 5. The agency shall develop and implement a program 40 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 that requires Medicaid practitioners who prescribe drugs to 2 use a counterfeit-proof prescription pad for Medicaid 3 prescriptions. The agency shall require the use of 4 standardized counterfeit-proof prescription pads by 5 Medicaid-participating prescribers or prescribers who write 6 prescriptions for Medicaid recipients. The agency may 7 implement the program in targeted geographic areas or 8 statewide. 9 6. The agency may enter into arrangements that require 10 manufacturers of generic drugs prescribed to Medicaid 11 recipients to provide rebates of at least 15.1 percent of the 12 average manufacturer price for the manufacturer's generic 13 products. These arrangements shall require that if a 14 generic-drug manufacturer pays federal rebates for 15 Medicaid-reimbursed drugs at a level below 15.1 percent, the 16 manufacturer must provide a supplemental rebate to the state 17 in an amount necessary to achieve a 15.1-percent rebate level. 18 7. The agency may establish a preferred drug formulary 19 in accordance with 42 U.S.C. s. 1396r-8, and, pursuant to the 20 establishment of such formulary, it is authorized to negotiate 21 supplemental rebates from manufacturers that are in addition 22 to those required by Title XIX of the Social Security Act and 23 at no less than 14 percent of the average manufacturer price 24 as defined in 42 U.S.C. s. 1936 on the last day of a quarter 25 unless the federal or supplemental rebate, or both, equals or 26 exceeds 29 percent. There is no upper limit on the 27 supplemental rebates the agency may negotiate. The agency may 28 determine that specific products, brand-name or generic, are 29 competitive at lower rebate percentages. Agreement to pay the 30 minimum supplemental rebate percentage will guarantee a 31 manufacturer that the Medicaid Pharmaceutical and Therapeutics 41 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 Committee will consider a product for inclusion on the 2 preferred drug formulary. However, a pharmaceutical 3 manufacturer is not guaranteed placement on the formulary by 4 simply paying the minimum supplemental rebate. Agency 5 decisions will be made on the clinical efficacy of a drug and 6 recommendations of the Medicaid Pharmaceutical and 7 Therapeutics Committee, as well as the price of competing 8 products minus federal and state rebates. The agency is 9 authorized to contract with an outside agency or contractor to 10 conduct negotiations for supplemental rebates. For the 11 purposes of this section, the term "supplemental rebates" 12 means cash rebates. Effective July 1, 2004, value-added 13 programs as a substitution for supplemental rebates are 14 prohibited. The agency is authorized to seek any federal 15 waivers to implement this initiative. 16 8. The agency shall establish an advisory committee 17 for the purposes of studying the feasibility of using a 18 restricted drug formulary for nursing home residents and other 19 institutionalized adults. The committee shall be comprised of 20 seven members appointed by the Secretary of Health Care 21 Administration. The committee members shall include two 22 physicians licensed under chapter 458 or chapter 459; three 23 pharmacists licensed under chapter 465 and appointed from a 24 list of recommendations provided by the Florida Long-Term Care 25 Pharmacy Alliance; and two pharmacists licensed under chapter 26 465. 27 9. The Agency for Health Care Administration shall 28 expand home delivery of pharmacy products. To assist Medicaid 29 patients in securing their prescriptions and reduce program 30 costs, the agency shall expand its current mail-order-pharmacy 31 diabetes-supply program to include all generic and brand-name 42 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 drugs used by Medicaid patients with diabetes. Medicaid 2 recipients in the current program may obtain nondiabetes drugs 3 on a voluntary basis. This initiative is limited to the 4 geographic area covered by the current contract. The agency 5 may seek and implement any federal waivers necessary to 6 implement this subparagraph. 7 10. The agency shall limit to one dose per month any 8 drug prescribed to treat erectile dysfunction. 9 11.a. The agency shall implement a Medicaid behavioral 10 drug management system. The agency may contract with a vendor 11 that has experience in operating behavioral drug management 12 systems to implement this program. The agency is authorized to 13 seek federal waivers to implement this program. 14 b. The agency, in conjunction with the Department of 15 Children and Family Services, may implement the Medicaid 16 behavioral drug management system that is designed to improve 17 the quality of care and behavioral health prescribing 18 practices based on best practice guidelines, improve patient 19 adherence to medication plans, reduce clinical risk, and lower 20 prescribed drug costs and the rate of inappropriate spending 21 on Medicaid behavioral drugs. The program shall include the 22 following elements: 23 (I) Provide for the development and adoption of best 24 practice guidelines for behavioral health-related drugs such 25 as antipsychotics, antidepressants, and medications for 26 treating bipolar disorders and other behavioral conditions; 27 translate them into practice; review behavioral health 28 prescribers and compare their prescribing patterns to a number 29 of indicators that are based on national standards; and 30 determine deviations from best practice guidelines. 31 (II) Implement processes for providing feedback to and 43 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 educating prescribers using best practice educational 2 materials and peer-to-peer consultation. 3 (III) Assess Medicaid beneficiaries who are outliers 4 in their use of behavioral health drugs with regard to the 5 numbers and types of drugs taken, drug dosages, combination 6 drug therapies, and other indicators of improper use of 7 behavioral health drugs. 8 (IV) Alert prescribers to patients who fail to refill 9 prescriptions in a timely fashion, are prescribed multiple 10 same-class behavioral health drugs, and may have other 11 potential medication problems. 12 (V) Track spending trends for behavioral health drugs 13 and deviation from best practice guidelines. 14 (VI) Use educational and technological approaches to 15 promote best practices, educate consumers, and train 16 prescribers in the use of practice guidelines. 17 (VII) Disseminate electronic and published materials. 18 (VIII) Hold statewide and regional conferences. 19 (IX) Implement a disease management program with a 20 model quality-based medication component for severely mentally 21 ill individuals and emotionally disturbed children who are 22 high users of care. 23 c. If the agency is unable to negotiate a contract 24 with one or more manufacturers to finance and guarantee 25 savings associated with a behavioral drug management program 26 by September 1, 2004, the four-brand drug limit and preferred 27 drug list prior-authorization requirements shall apply to 28 mental health-related drugs, notwithstanding any provision in 29 subparagraph 1. The agency is authorized to seek federal 30 waivers to implement this policy. 31 12.a. The agency shall implement a Medicaid 44 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 prescription-drug-management system. The agency may contract 2 with a vendor that has experience in operating 3 prescription-drug-management systems in order to implement 4 this system. Any management system that is implemented in 5 accordance with this subparagraph must rely on cooperation 6 between physicians and pharmacists to determine appropriate 7 practice patterns and clinical guidelines to improve the 8 prescribing, dispensing, and use of drugs in the Medicaid 9 program. The agency may seek federal waivers to implement this 10 program. 11 b. The drug-management system must be designed to 12 improve the quality of care and prescribing practices based on 13 best-practice guidelines, improve patient adherence to 14 medication plans, reduce clinical risk, and lower prescribed 15 drug costs and the rate of inappropriate spending on Medicaid 16 prescription drugs. The program must: 17 (I) Provide for the development and adoption of 18 best-practice guidelines for the prescribing and use of drugs 19 in the Medicaid program, including translating best-practice 20 guidelines into practice; reviewing prescriber patterns and 21 comparing them to indicators that are based on national 22 standards and practice patterns of clinical peers in their 23 community, statewide, and nationally; and determine deviations 24 from best-practice guidelines. 25 (II) Implement processes for providing feedback to and 26 educating prescribers using best-practice educational 27 materials and peer-to-peer consultation. 28 (III) Assess Medicaid recipients who are outliers in 29 their use of a single or multiple prescription drugs with 30 regard to the numbers and types of drugs taken, drug dosages, 31 combination drug therapies, and other indicators of improper 45 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 use of prescription drugs. 2 (IV) Alert prescribers to patients who fail to refill 3 prescriptions in a timely fashion, are prescribed multiple 4 drugs that may be redundant or contraindicated, or may have 5 other potential medication problems. 6 (V) Track spending trends for prescription drugs and 7 deviation from best-practice guidelines. 8 (VI) Use educational and technological approaches to 9 promote best practices, educate consumers, and train 10 prescribers in the use of practice guidelines. 11 (VII) Disseminate electronic and published materials. 12 (VIII) Hold statewide and regional conferences. 13 (IX) Implement disease-management programs in 14 cooperation with physicians and pharmacists, along with a 15 model quality-based medication component for individuals 16 having chronic medical conditions. 17 13.12. The agency is authorized to contract for drug 18 rebate administration, including, but not limited to, 19 calculating rebate amounts, invoicing manufacturers, 20 negotiating disputes with manufacturers, and maintaining a 21 database of rebate collections. 22 14.13. The agency may specify the preferred daily 23 dosing form or strength for the purpose of promoting best 24 practices with regard to the prescribing of certain drugs as 25 specified in the General Appropriations Act and ensuring 26 cost-effective prescribing practices. 27 15.14. The agency may require prior authorization for 28 the off-label use of Medicaid-covered prescribed drugs as 29 specified in the General Appropriations Act. The agency may, 30 but is not required to, preauthorize the use of a product for 31 an indication not in the approved labeling. Prior 46 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 authorization may require the prescribing professional to 2 provide information about the rationale and supporting medical 3 evidence for the off-label use of a drug. 4 16.15. The agency shall implement a return and reuse 5 program for drugs dispensed by pharmacies to institutional 6 recipients, which includes payment of a $5 restocking fee for 7 the implementation and operation of the program. The return 8 and reuse program shall be implemented electronically and in a 9 manner that promotes efficiency. The program must permit a 10 pharmacy to exclude drugs from the program if it is not 11 practical or cost-effective for the drug to be included and 12 must provide for the return to inventory of drugs that cannot 13 be credited or returned in a cost-effective manner. The agency 14 shall determine if the program has reduced the amount of 15 Medicaid prescription drugs which are destroyed on an annual 16 basis and if there are additional ways to ensure more 17 prescription drugs are not destroyed which could safely be 18 reused. The agency's conclusion and recommendations shall be 19 reported to the Legislature by December 1, 2005. 20 (b) The agency shall implement this subsection to the 21 extent that funds are appropriated to administer the Medicaid 22 prescribed-drug spending-control program. The agency may 23 contract all or any part of this program to private 24 organizations. 25 (c) The agency shall submit quarterly reports to the 26 Governor, the President of the Senate, and the Speaker of the 27 House of Representatives which must include, but need not be 28 limited to, the progress made in implementing this subsection 29 and its effect on Medicaid prescribed-drug expenditures. 30 (40) Notwithstanding the provisions of chapter 287, 31 the agency may, at its discretion, renew a contract or 47 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 contracts for fiscal intermediary services one or more times 2 for such periods as the agency may decide; however, all such 3 renewals may not combine to exceed a total period longer than 4 the term of the original contract. 5 (41) The agency shall provide for the development of a 6 demonstration project by establishment in Miami-Dade County of 7 a long-term-care facility licensed pursuant to chapter 395 to 8 improve access to health care for a predominantly minority, 9 medically underserved, and medically complex population and to 10 evaluate alternatives to nursing home care and general acute 11 care for such population. Such project is to be located in a 12 health care condominium and colocated with licensed facilities 13 providing a continuum of care. The establishment of this 14 project is not subject to the provisions of s. 408.036 or s. 15 408.039. The agency shall report its findings to the Governor, 16 the President of the Senate, and the Speaker of the House of 17 Representatives by January 1, 2003. 18 (42) The agency shall develop and implement a 19 utilization management program for Medicaid-eligible 20 recipients for the management of occupational, physical, 21 respiratory, and speech therapies. The agency shall establish 22 a utilization program that may require prior authorization in 23 order to ensure medically necessary and cost-effective 24 treatments. The program shall be operated in accordance with a 25 federally approved waiver program or state plan amendment. The 26 agency may seek a federal waiver or state plan amendment to 27 implement this program. The agency may also competitively 28 procure these services from an outside vendor on a regional or 29 statewide basis. 30 (43) The agency may contract on a prepaid or fixed-sum 31 basis with appropriately licensed prepaid dental health plans 48 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 to provide dental services. 2 (44) The Agency for Health Care Administration shall 3 ensure that any Medicaid managed care plan as defined in s. 4 409.9122(2)(h), whether paid on a capitated basis or a shared 5 savings basis, is cost-effective. For purposes of this 6 subsection, the term "cost-effective" means that a network's 7 per-member, per-month costs to the state, including, but not 8 limited to, fee-for-service costs, administrative costs, and 9 case-management fees, must be no greater than the state's 10 costs associated with contracts for Medicaid services 11 established under subsection (3), which shall be actuarially 12 adjusted for case mix, model, and service area. The agency 13 shall conduct actuarially sound audits adjusted for case mix 14 and model in order to ensure such cost-effectiveness and shall 15 publish the audit results on its Internet website and submit 16 the audit results annually to the Governor, the President of 17 the Senate, and the Speaker of the House of Representatives no 18 later than December 31 of each year. Contracts established 19 pursuant to this subsection which are not cost-effective may 20 not be renewed. 21 (45) Subject to the availability of funds, the agency 22 shall mandate a recipient's participation in a provider 23 lock-in program, when appropriate, if a recipient is found by 24 the agency to have used Medicaid goods or services at a 25 frequency or amount not medically necessary, limiting the 26 receipt of goods or services to medically necessary providers 27 after the 21-day appeal process has ended, for a period of not 28 less than 1 year. The lock-in programs shall include, but are 29 not limited to, pharmacies, medical doctors, and infusion 30 clinics. The limitation does not apply to emergency services 31 and care provided to the recipient in a hospital emergency 49 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 department. The agency shall seek any federal waivers 2 necessary to implement this subsection. The agency shall adopt 3 any rules necessary to comply with or administer this 4 subsection. 5 (46) The agency shall seek a federal waiver for 6 permission to terminate the eligibility of a Medicaid 7 recipient who has been found to have committed fraud, through 8 judicial or administrative determination, two times in a 9 period of 5 years. 10 (47) The agency shall conduct a study of available 11 electronic systems for the purpose of verifying the identity 12 and eligibility of a Medicaid recipient. The agency shall 13 recommend to the Legislature a plan to implement an electronic 14 verification system for Medicaid recipients by January 31, 15 2005. 16 (48) A provider is not entitled to enrollment in the 17 Medicaid provider network. The agency may implement a Medicaid 18 fee-for-service provider network controls, including, but not 19 limited to, competitive procurement and provider 20 credentialing. If a credentialing process is used, the agency 21 may limit its provider network based upon the following 22 considerations: beneficiary access to care, provider 23 availability, provider quality standards and quality assurance 24 processes, cultural competency, demographic characteristics of 25 beneficiaries, practice standards, service wait times, 26 provider turnover, provider licensure and accreditation 27 history, program integrity history, peer review, Medicaid 28 policy and billing compliance records, clinical and medical 29 record audit findings, and such other areas that are 30 considered necessary by the agency to ensure the integrity of 31 the program. 50 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 (49) The agency shall contract with established 2 minority physician networks that provide services to 3 historically underserved minority patients. The networks must 4 provide cost-effective Medicaid services, comply with the 5 requirements to be a MediPass provider, and provide their 6 primary care physicians with access to data and other 7 management tools necessary to assist them in ensuring the 8 appropriate use of services, including inpatient hospital 9 services and pharmaceuticals. 10 (a) The agency shall provide for the development and 11 expansion of minority physician networks in each service area 12 to provide services to Medicaid recipients who are eligible to 13 participate under federal law and rules. 14 (b) The agency shall reimburse each minority physician 15 network as a fee-for-service provider, including the case 16 management fee for primary care, or as a capitated rate 17 provider for Medicaid services. Any savings shall be shared 18 with the minority physician networks pursuant to the contract. 19 (c) For purposes of this subsection, the term 20 "cost-effective" means that a network's per-member, per-month 21 costs to the state, including, but not limited to, 22 fee-for-service costs, administrative costs, and 23 case-management fees, must be no greater than the state's 24 costs associated with contracts for Medicaid services 25 established under subsection (3), which shall be actuarially 26 adjusted for case mix, model, and service area. The agency 27 shall conduct actuarially sound audits adjusted for case mix 28 and model in order to ensure such cost-effectiveness and shall 29 publish the audit results on its Internet website and submit 30 the audit results annually to the Governor, the President of 31 the Senate, and the Speaker of the House of Representatives no 51 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 later than December 31. Contracts established pursuant to this 2 subsection which are not cost-effective may not be renewed. 3 (d) The agency may apply for any federal waivers 4 needed to implement this subsection. 5 (50) To the extent permitted by federal law and as 6 allowed under s. 409.906, the agency shall provide 7 reimbursement for emergency mental health care services for 8 Medicaid recipients in crisis-stabilization facilities 9 licensed under s. 394.875 as long as those services are less 10 expensive than the same services provided in a hospital 11 setting. 12 Section 2. Section 409.91211, Florida Statutes, is 13 created to read: 14 409.91211 Medicaid managed care pilot program.-- 15 (1) The agency is authorized to seek experimental, 16 pilot, or demonstration project waivers, pursuant to s. 1115 17 of the Social Security Act, to create a statewide initiative 18 to provide for a more efficient and effective service delivery 19 system that enhances quality of care and client outcomes in 20 the Florida Medicaid program pursuant to this section. Phase 21 one of the demonstration shall be implemented in two 22 geographic areas. One demonstration site shall include only 23 Broward County. A second demonstration site shall initially 24 include Duval County and shall be expanded to include Baker, 25 Clay, and Nassau Counties within 1 year after the Duval County 26 program becomes operational. This waiver authority is 27 contingent upon federal approval to preserve the 28 upper-payment-limit funding mechanism for hospitals, including 29 a guarantee of a reasonable growth factor, a methodology to 30 allow the use of a portion of these funds to serve as a risk 31 pool for demonstration sites, provisions to preserve the 52 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 state's ability to use intergovernmental transfers, and 2 provisions to protect the disproportionate share program 3 authorized pursuant to this chapter. Upon completion of the 4 evaluation conducted under section 3 of this act, the agency 5 may request statewide expansion of the demonstration projects. 6 Statewide phase-in to additional counties shall be contingent 7 upon review and approval by the Legislature. 8 (2) The Legislature intends for the capitated managed 9 care pilot program to: 10 (a) Provide recipients in Medicaid fee-for-service or 11 the MediPass program a comprehensive and coordinated capitated 12 managed care system for all health care services specified in 13 ss. 409.905 and 409.906. 14 (b) Stabilize Medicaid expenditures under the pilot 15 program compared to Medicaid expenditures in the pilot area 16 for the 3 years before implementation of the pilot program, 17 while ensuring: 18 1. Consumer education and choice. 19 2. Access to medically necessary services. 20 3. Coordination of preventative, acute, and long-term 21 care. 22 4. Reductions in unnecessary service utilization. 23 (c) Provide an opportunity to evaluate the feasibility 24 of statewide implementation of capitated managed care networks 25 as a replacement for the current Medicaid fee-for-service and 26 MediPass systems. 27 (3) The agency shall have the following powers, 28 duties, and responsibilities with respect to the development 29 of a pilot program: 30 (a) To develop and recommend a system to deliver all 31 mandatory services specified in s. 409.905 and optional 53 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 services specified in s. 409.906, as approved by the Centers 2 for Medicare and Medicaid Services and the Legislature in the 3 waiver pursuant to this section. Services to recipients under 4 plan benefits shall include emergency services provided under 5 s. 409.9128. 6 (b) To recommend Medicaid-eligibility categories, from 7 those specified in ss. 409.903 and 409.904, which shall be 8 included in the pilot program. 9 (c) To determine and recommend how to design the 10 managed care pilot program in order to take maximum advantage 11 of all available state and federal funds, including those 12 obtained through intergovernmental transfers, the 13 upper-payment-level funding systems, and the disproportionate 14 share program. 15 (d) To determine and recommend actuarially sound, 16 risk-adjusted capitation rates for Medicaid recipients in the 17 pilot program which can be separated to cover comprehensive 18 care, enhanced services, and catastrophic care. 19 (e) To determine and recommend policies and guidelines 20 for phasing in financial risk for approved provider service 21 networks over a 3-year period. These shall include an option 22 to pay fee-for-service rates that may include a 23 savings-settlement option for at least 2 years. This model may 24 be converted to a risk-adjusted capitated rate in the third 25 year of operation. Federally qualified health centers may be 26 offered an opportunity to accept or decline a contract to 27 participate in any provider network for prepaid primary care 28 services. 29 (f) To determine and recommend provisions related to 30 stop-loss requirements and the transfer of excess cost to 31 catastrophic coverage that accommodates the risks associated 54 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 with the development of the pilot program. 2 (g) To determine and recommend a process to be used by 3 the Social Services Estimating Conference to determine and 4 validate the rate of growth of the per-member costs of 5 providing Medicaid services under the managed care pilot 6 program. 7 (h) To determine and recommend program standards and 8 credentialing requirements for capitated managed care networks 9 to participate in the pilot program, including those related 10 to fiscal solvency, quality of care, and adequacy of access to 11 health care providers. It is the intent of the Legislature 12 that, to the extent possible, any pilot program authorized by 13 the state under this section include any federally qualified 14 health center, federally qualified rural health clinic, county 15 health department, or other federally, state, or locally 16 funded entity that serves the geographic areas within the 17 boundaries of the pilot program that requests to participate. 18 This paragraph does not relieve an entity that qualifies as a 19 capitated managed care network under this section from any 20 other licensure or regulatory requirements contained in state 21 or federal law which would otherwise apply to the entity. The 22 standards and credentialing requirements shall be based upon, 23 but are not limited to: 24 1. Compliance with the accreditation requirements as 25 provided in s. 641.512. 26 2. Compliance with early and periodic screening, 27 diagnosis, and treatment screening requirements under federal 28 law. 29 3. The percentage of voluntary disenrollments. 30 4. Immunization rates. 31 5. Standards of the National Committee for Quality 55 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 Assurance and other approved accrediting bodies. 2 6. Recommendations of other authoritative bodies. 3 7. Specific requirements of the Medicaid program, or 4 standards designed to specifically meet the unique needs of 5 Medicaid recipients. 6 8. Compliance with the health quality improvement 7 system as established by the agency, which incorporates 8 standards and guidelines developed by the Centers for Medicare 9 and Medicaid Services as part of the quality assurance reform 10 initiative. 11 9. The network's infrastructure capacity to manage 12 financial transactions, recordkeeping, data collection, and 13 other administrative functions. 14 10. The network's ability to submit any financial, 15 programmatic, or patient-encounter data or other information 16 required by the agency to determine the actual services 17 provided and the cost of administering the plan. 18 (i) To develop and recommend a mechanism for providing 19 information to Medicaid recipients for the purpose of 20 selecting a capitated managed care plan. For each plan 21 available to a recipient, the agency, at a minimum shall 22 ensure that the recipient is provided with: 23 1. A list and description of the benefits provided. 24 2. Information about cost sharing. 25 3. Plan performance data, if available. 26 4. An explanation of benefit limitations. 27 5. Contact information, including identification of 28 providers participating in the network, geographic locations, 29 and transportation limitations. 30 6. Any other information the agency determines would 31 facilitate a recipient's understanding of the plan or 56 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 insurance that would best meet his or her needs. 2 (j) To develop and recommend a system to ensure that 3 there is a record of recipient acknowledgment that choice 4 counseling has been provided. 5 (k) To develop and recommend a choice counseling 6 system to ensure that the choice counseling process and 7 related material are designed to provide counseling through 8 face-to-face interaction, by telephone, and in writing and 9 through other forms of relevant media. Materials shall be 10 written at the fourth-grade reading level and available in a 11 language other than English when 5 percent of the county 12 speaks a language other than English. Choice counseling shall 13 also use language lines and other services for impaired 14 recipients, such as TTD/TTY. 15 (l) To develop and recommend a system that prohibits 16 capitated managed care plans, their representatives, and 17 providers employed by or contracted with the capitated managed 18 care plans from recruiting persons eligible for or enrolled in 19 Medicaid, from providing inducements to Medicaid recipients to 20 select a particular capitated managed care plan, and from 21 prejudicing Medicaid recipients against other capitated 22 managed care plans. The system shall require the entity 23 performing choice counseling to determine if the recipient has 24 made a choice of a plan or has opted out because of duress, 25 threats, payment to the recipient, or incentives promised to 26 the recipient by a third party. If the choice counseling 27 entity determines that the decision to choose a plan was 28 unlawfully influenced or a plan violated any of the provisions 29 of s. 409.912(21), the choice counseling entity shall 30 immediately report the violation to the agency's program 31 integrity section for investigation. Verification of choice 57 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 counseling by the recipient shall include a stipulation that 2 the recipient acknowledges the provisions of this subsection. 3 (m) To develop and recommend a choice counseling 4 system that promotes health literacy and provides information 5 aimed to reduce minority health disparities through outreach 6 activities for Medicaid recipients. 7 (n) To develop and recommend a system for the agency 8 to contract with entities to perform choice counseling. The 9 agency may establish standards and performance contracts, 10 including standards requiring the contractor to hire choice 11 counselors who are representative of the state's diverse 12 population and to train choice counselors in working with 13 culturally diverse populations. 14 (o) To determine and recommend descriptions of the 15 eligibility assignment processes which will be used to 16 facilitate client choice while ensuring pilot programs of 17 adequate enrollment levels. These processes shall ensure that 18 pilot sites have sufficient levels of enrollment to conduct a 19 valid test of the managed care pilot program within a 2-year 20 timeframe. 21 (p) To develop and recommend a system to monitor the 22 provision of health care services in the pilot program, 23 including utilization and quality of health care services for 24 the purpose of ensuring access to medically necessary 25 services. This system shall include an encounter 26 data-information system that collects and reports utilization 27 information. The system shall include a method for verifying 28 data integrity within the database and within the provider's 29 medical records. 30 (q) To recommend a grievance-resolution process for 31 Medicaid recipients enrolled in a capitated managed care 58 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 network under the pilot program modeled after the subscriber 2 assistance panel, as created in s. 408.7056. This process 3 shall include a mechanism for an expedited review of no 4 greater than 24 hours after notification of a grievance if the 5 life of a Medicaid recipient is in imminent and emergent 6 jeopardy. 7 (r) To recommend a grievance-resolution process for 8 health care providers employed by or contracted with a 9 capitated managed care network under the pilot program in 10 order to settle disputes among the provider and the managed 11 care network or the provider and the agency. 12 (s) To develop and recommend criteria to designate 13 health care providers as eligible to participate in the pilot 14 program. The agency and capitated managed care networks must 15 follow national guidelines for selecting health care 16 providers, whenever available. These criteria must include at 17 a minimum those criteria specified in s. 409.907. 18 (t) To develop and recommend health care provider 19 agreements for participation in the pilot program. 20 (u) To require that all health care providers under 21 contract with the pilot program be duly licensed in the state, 22 if such licensure is available, and meet other criteria as may 23 be established by the agency. These criteria shall include at 24 a minimum those criteria specified in s. 409.907. 25 (v) To develop and recommend agreements with other 26 state or local governmental programs or institutions for the 27 coordination of health care to eligible individuals receiving 28 services from such programs or institutions. 29 (w) To develop and recommend a system to oversee the 30 activities of pilot program participants, health care 31 providers, capitated managed care networks, and their 59 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 representatives in order to prevent fraud or abuse, 2 overutilization or duplicative utilization, underutilization 3 or inappropriate denial of services, and neglect of 4 participants and to recover overpayments as appropriate. For 5 the purposes of this paragraph, the terms "abuse" and "fraud" 6 have the meanings as provided in s. 409.913. The agency must 7 refer incidents of suspected fraud, abuse, overutilization and 8 duplicative utilization, and underutilization or inappropriate 9 denial of services to the appropriate regulatory agency. 10 (x) To develop and provide actuarial and benefit 11 design analyses that indicate the effect on capitation rates 12 and benefits offered in the pilot program over a prospective 13 5-year period based on the following assumptions: 14 1. Growth in capitation rates which is limited to the 15 estimated growth rate in general revenue. 16 2. Growth in capitation rates which is limited to the 17 average growth rate over the last 3 years in per-recipient 18 Medicaid expenditures. 19 3. Growth in capitation rates which is limited to the 20 growth rate of aggregate Medicaid expenditures between the 21 2003-2004 fiscal year and the 2004-2005 fiscal year. 22 (y) To develop a mechanism to require capitated 23 managed care plans to reimburse qualified emergency service 24 providers, including, but not limited to, ambulance services, 25 in accordance with ss. 409.908 and 409.9128. The pilot program 26 must include a provision for continuing fee-for-service 27 payments for emergency services, including but not limited to, 28 individuals who access ambulance services or emergency 29 departments and who are subsequently determined to be eligible 30 for Medicaid services. 31 (z) To develop a system whereby school districts 60 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 participating in the certified school match program pursuant 2 to ss. 409.908(21) and 1011.70 shall be reimbursed by 3 Medicaid, subject to the limitations of s. 1011.70(1), for a 4 Medicaid-eligible child participating in the services as 5 authorized in s. 1011.70, as provided for in s. 409.9071, 6 regardless of whether the child is enrolled in a capitated 7 managed care network. Capitated managed care networks must 8 make a good-faith effort to execute agreements with school 9 districts regarding the coordinated provision of services 10 authorized under s. 1011.70. County health departments 11 delivering school-based services pursuant to ss. 381.0056 and 12 381.0057 must be reimbursed by Medicaid for the federal share 13 for a Medicaid-eligible child who receives Medicaid-covered 14 services in a school setting, regardless of whether the child 15 is enrolled in a capitated managed care network. Capitated 16 managed care networks must make a good-faith effort to execute 17 agreements with county health departments regarding the 18 coordinated provision of services to a Medicaid-eligible 19 child. To ensure continuity of care for Medicaid patients, the 20 agency, the Department of Health, and the Department of 21 Education shall develop procedures for ensuring that a 22 student's capitated managed care network provider receives 23 information relating to services provided in accordance with 24 ss. 381.0056, 381.0057, 409.9071, and 1011.70. 25 (aa) To develop and recommend a mechanism whereby 26 Medicaid recipients who are already enrolled in a managed care 27 plan or the MediPass program in the pilot areas shall be 28 offered the opportunity to change to capitated managed care 29 plans on a staggered basis, as defined by the agency. All 30 Medicaid recipients shall have 30 days in which to make a 31 choice of capitated managed care plans. Those Medicaid 61 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 recipients who do not make a choice shall be assigned to a 2 capitated managed care plan in accordance with paragraph 3 (4)(a). To facilitate continuity of care for a Medicaid 4 recipient who is also a recipient of Supplemental Security 5 Income (SSI), prior to assigning the SSI recipient to a 6 capitated managed care plan, the agency shall determine 7 whether the SSI recipient has an ongoing relationship with a 8 provider or capitated managed care plan, and if so, the agency 9 shall assign the SSI recipient to that provider or capitated 10 managed care plan where feasible. Those SSI recipients who do 11 not have such a provider relationship shall be assigned to a 12 capitated managed care plan provider in accordance with 13 paragraph (4)(a). 14 (bb) To develop and recommend a service delivery 15 alternative for children having chronic medical conditions 16 which establishes a medical home project to provide primary 17 care services to this population. The project shall provide 18 community-based primary care services that are integrated with 19 other subspecialties to meet the medical, developmental, and 20 emotional needs for children and their families. This project 21 shall include an evaluation component to determine impacts on 22 hospitalizations, length of stays, emergency room visits, 23 costs, and access to care, including specialty care and 24 patient, and family satisfaction. 25 (cc) To develop and recommend service delivery 26 mechanisms within capitated managed care plans to provide 27 Medicaid services as specified in ss. 409.905 and 409.906 to 28 persons with developmental disabilities sufficient to meet the 29 medical, developmental, and emotional needs of these persons. 30 (dd) To develop and recommend service delivery 31 mechanisms within capitated managed care plans to provide 62 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 Medicaid services as specified in ss. 409.905 and 409.906 to 2 Medicaid-eligible children in foster care. These services must 3 be coordinated with community-based care providers as 4 specified in s. 409.1675, where available, and be sufficient 5 to meet the medical, developmental, and emotional needs of 6 these children. 7 (4)(a) A Medicaid recipient in the pilot area who is 8 not currently enrolled in a capitated managed care plan upon 9 implementation is not eligible for services as specified in 10 ss. 409.905 and 409.906, for the amount of time that the 11 recipient does not enroll in a capitated managed care network. 12 If a Medicaid recipient has not enrolled in a capitated 13 managed care plan within 30 days after eligibility, the agency 14 shall assign the Medicaid recipient to a capitated managed 15 care plan based on the assessed needs of the recipient as 16 determined by the agency. When making assignments, the agency 17 shall take into account the following criteria: 18 1. A capitated managed care network has sufficient 19 network capacity to meet the need of members. 20 2. The capitated managed care network has previously 21 enrolled the recipient as a member, or one of the capitated 22 managed care network's primary care providers has previously 23 provided health care to the recipient. 24 3. The agency has knowledge that the member has 25 previously expressed a preference for a particular capitated 26 managed care network as indicated by Medicaid fee-for-service 27 claims data, but has failed to make a choice. 28 4. The capitated managed care network's primary care 29 providers are geographically accessible to the recipient's 30 residence. 31 (b) When more than one capitated managed care network 63 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 provider meets the criteria specified in paragraph (3)(h), the 2 agency shall make recipient assignments consecutively by 3 family unit. 4 (c) The agency may not engage in practices that are 5 designed to favor one capitated managed care plan over another 6 or that are designed to influence Medicaid recipients to 7 enroll in a particular capitated managed care network in order 8 to strengthen its particular fiscal viability. 9 (d) After a recipient has made a selection or has been 10 enrolled in a capitated managed care network, the recipient 11 shall have 90 days in which to voluntarily disenroll and 12 select another capitated managed care network. After 90 days, 13 no further changes may be made except for cause. Cause shall 14 include, but not be limited to, poor quality of care, lack of 15 access to necessary specialty services, an unreasonable delay 16 or denial of service, inordinate or inappropriate changes of 17 primary care providers, service access impairments due to 18 significant changes in the geographic location of services, or 19 fraudulent enrollment. The agency may require a recipient to 20 use the capitated managed care network's grievance process as 21 specified in paragraph (3)(g) prior to the agency's 22 determination of cause, except in cases in which immediate 23 risk of permanent damage to the recipient's health is alleged. 24 The grievance process, when used, must be completed in time to 25 permit the recipient to disenroll no later than the first day 26 of the second month after the month the disenrollment request 27 was made. If the capitated managed care network, as a result 28 of the grievance process, approves an enrollee's request to 29 disenroll, the agency is not required to make a determination 30 in the case. The agency must make a determination and take 31 final action on a recipient's request so that disenrollment 64 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 occurs no later than the first day of the second month after 2 the month the request was made. If the agency fails to act 3 within the specified timeframe, the recipient's request to 4 disenroll is deemed to be approved as of the date agency 5 action was required. Recipients who disagree with the agency's 6 finding that cause does not exist for disenrollment shall be 7 advised of their right to pursue a Medicaid fair hearing to 8 dispute the agency's finding. 9 (e) The agency shall apply for federal waivers from 10 the Centers for Medicare and Medicaid Services to lock 11 eligible Medicaid recipients into a capitated managed care 12 network for 12 months after an open enrollment period. After 13 12 months of enrollment, a recipient may select another 14 capitated managed care network. However, nothing shall prevent 15 a Medicaid recipient from changing primary care providers 16 within the capitated managed care network during the 12-month 17 period. 18 (f) The agency shall apply for federal waivers from 19 the Centers for Medicare and Medicaid Services to allow 20 recipients to purchase health care coverage through an 21 employer-sponsored health insurance plan instead of through a 22 Medicaid-certified plan. This provision shall be known as the 23 opt-out option. 24 1. A recipient who chooses the Medicaid opt-out option 25 shall have an opportunity for a specified period of time, as 26 authorized under a waiver granted by the Centers for Medicare 27 and Medicaid Services, to select and enroll in a 28 Medicaid-certified plan. If the recipient remains in the 29 employer-sponsored plan after the specified period, the 30 recipient shall remain in the opt-out program for at least 1 31 year or until the recipient no longer has access to 65 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 employer-sponsored coverage, until the employer's open 2 enrollment period for a person who opts out in order to 3 participate in employer-sponsored coverage, or until the 4 person is no longer eligible for Medicaid, whichever time 5 period is shorter. 6 2. Notwithstanding any other provision of this 7 section, coverage, cost sharing, and any other component of 8 employer-sponsored health insurance shall be governed by 9 applicable state and federal laws. 10 (5) This section does not authorize the agency to 11 implement any provision of s. 1115 of the Social Security Act 12 experimental, pilot, or demonstration project waiver to reform 13 the state Medicaid program in any part of the state other than 14 the two geographic areas specified in this section unless 15 approved by the Legislature. 16 (6) The agency shall develop and submit for approval 17 applications for waivers of applicable federal laws and 18 regulations as necessary to implement the managed care pilot 19 project as defined in this section. The agency shall post all 20 waiver applications under this section on its Internet website 21 30 days before submitting the applications to the United 22 States Centers for Medicare and Medicaid Services. All waiver 23 applications shall be provided for review and comment to the 24 appropriate committees of the Senate and House of 25 Representatives for at least 10 working days prior to 26 submission. All waivers submitted to and approved by the 27 United States Centers for Medicare and Medicaid Services under 28 this section must be approved by the Legislature. Federally 29 approved waivers must be submitted to the President of the 30 Senate and the Speaker of the House of Representatives for 31 referral to the appropriate legislative committees. The 66 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 appropriate committees shall recommend whether to approve the 2 implementation of any waivers to the Legislature as a whole. 3 The agency shall submit a plan containing a recommended 4 timeline for implementation of any waivers and budgetary 5 projections of the effect of the pilot program under this 6 section on the total Medicaid budget for the 2006-2007 through 7 2009-2010 state fiscal years. This implementation plan shall 8 be submitted to the President of the Senate and the Speaker of 9 the House of Representatives at the same time any waivers are 10 submitted for consideration by the Legislature. 11 (7) Upon review and approval of the applications for 12 waivers of applicable federal laws and regulations to 13 implement the managed care pilot program by the Legislature, 14 the agency may initiate adoption of rules pursuant to ss. 15 120.536(1) and 120.54 to implement and administer the managed 16 care pilot program as provided in this section. 17 Section 3. The Office of Program Policy Analysis and 18 Government Accountability, in consultation with the Auditor 19 General, shall comprehensively evaluate the two managed care 20 pilot programs created under section 409.91211, Florida 21 Statutes. The evaluation shall begin with the implementation 22 of the managed care model in the pilot areas and continue for 23 24 months after the two pilot programs have enrolled Medicaid 24 recipients and started providing health care services. The 25 evaluation must include assessments of cost savings; consumer 26 education, choice, and access to services; coordination of 27 care; and quality of care by each eligibility category and 28 managed care plan in each pilot site. The evaluation must 29 describe administrative or legal barriers to the 30 implementation and operation of each pilot program and include 31 recommendations regarding statewide expansion of the managed 67 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 care pilot programs. The office shall submit an evaluation 2 report to the Governor, the President of the Senate, and the 3 Speaker of the House of Representatives no later than June 30, 4 2008. 5 Section 4. Section 409.9062, Florida Statutes, is 6 amended to read: 7 409.9062 Lung transplant services for Medicaid 8 recipients.--Subject to the availability of funds and subject 9 to any limitations or directions provided for in the General 10 Appropriations Act or chapter 216, the Agency for Health Care 11 Administration Medicaid program shall pay for medically 12 necessary lung transplant services for Medicaid recipients. 13 These payments must be used to reimburse approved lung 14 transplant facilities a global fee for providing lung 15 transplant services to Medicaid recipients. 16 Section 5. The sums of $401,098 from the General 17 Revenue Fund and $593,058 from the Medical Care Trust Fund are 18 appropriated to the Agency for Health Care Administration for 19 the purpose of implementing section 4 during the 2005-2006 20 fiscal year. 21 Section 6. Paragraphs (a) and (j) of subsection (2) of 22 section 409.9122, Florida Statutes, are amended to read: 23 409.9122 Mandatory Medicaid managed care enrollment; 24 programs and procedures.-- 25 (2)(a) The agency shall enroll in a managed care plan 26 or MediPass all Medicaid recipients, except those Medicaid 27 recipients who are: in an institution; enrolled in the 28 Medicaid medically needy program; or eligible for both 29 Medicaid and Medicare. Upon enrollment, individuals will be 30 able to change their managed care option during the 90-day opt 31 out period required by federal Medicaid regulations. The 68 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 agency is authorized to seek the necessary Medicaid state plan 2 amendment to implement this policy. However, to the extent 3 permitted by federal law, the agency may enroll in a managed 4 care plan or MediPass a Medicaid recipient who is exempt from 5 mandatory managed care enrollment, provided that: 6 1. The recipient's decision to enroll in a managed 7 care plan or MediPass is voluntary; 8 2. If the recipient chooses to enroll in a managed 9 care plan, the agency has determined that the managed care 10 plan provides specific programs and services which address the 11 special health needs of the recipient; and 12 3. The agency receives any necessary waivers from the 13 federal Centers for Medicare and Medicaid Services Health Care 14 Financing Administration. 15 16 The agency shall develop rules to establish policies by which 17 exceptions to the mandatory managed care enrollment 18 requirement may be made on a case-by-case basis. The rules 19 shall include the specific criteria to be applied when making 20 a determination as to whether to exempt a recipient from 21 mandatory enrollment in a managed care plan or MediPass. 22 School districts participating in the certified school match 23 program pursuant to ss. 409.908(21) and 1011.70 shall be 24 reimbursed by Medicaid, subject to the limitations of s. 25 1011.70(1), for a Medicaid-eligible child participating in the 26 services as authorized in s. 1011.70, as provided for in s. 27 409.9071, regardless of whether the child is enrolled in 28 MediPass or a managed care plan. Managed care plans shall make 29 a good faith effort to execute agreements with school 30 districts regarding the coordinated provision of services 31 authorized under s. 1011.70. County health departments 69 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 delivering school-based services pursuant to ss. 381.0056 and 2 381.0057 shall be reimbursed by Medicaid for the federal share 3 for a Medicaid-eligible child who receives Medicaid-covered 4 services in a school setting, regardless of whether the child 5 is enrolled in MediPass or a managed care plan. Managed care 6 plans shall make a good faith effort to execute agreements 7 with county health departments regarding the coordinated 8 provision of services to a Medicaid-eligible child. To ensure 9 continuity of care for Medicaid patients, the agency, the 10 Department of Health, and the Department of Education shall 11 develop procedures for ensuring that a student's managed care 12 plan or MediPass provider receives information relating to 13 services provided in accordance with ss. 381.0056, 381.0057, 14 409.9071, and 1011.70. 15 (j) The agency shall apply for a federal waiver from 16 the Centers for Medicare and Medicaid Services Health Care 17 Financing Administration to lock eligible Medicaid recipients 18 into a managed care plan or MediPass for 12 months after an 19 open enrollment period. After 12 months' enrollment, a 20 recipient may select another managed care plan or MediPass 21 provider. However, nothing shall prevent a Medicaid recipient 22 from changing primary care providers within the managed care 23 plan or MediPass program during the 12-month period. 24 Section 7. Subsection (2) of section 409.913, Florida 25 Statutes, is amended, and subsection (36) is added to that 26 section, to read: 27 409.913 Oversight of the integrity of the Medicaid 28 program.--The agency shall operate a program to oversee the 29 activities of Florida Medicaid recipients, and providers and 30 their representatives, to ensure that fraudulent and abusive 31 behavior and neglect of recipients occur to the minimum extent 70 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 possible, and to recover overpayments and impose sanctions as 2 appropriate. Beginning January 1, 2003, and each year 3 thereafter, the agency and the Medicaid Fraud Control Unit of 4 the Department of Legal Affairs shall submit a joint report to 5 the Legislature documenting the effectiveness of the state's 6 efforts to control Medicaid fraud and abuse and to recover 7 Medicaid overpayments during the previous fiscal year. The 8 report must describe the number of cases opened and 9 investigated each year; the sources of the cases opened; the 10 disposition of the cases closed each year; the amount of 11 overpayments alleged in preliminary and final audit letters; 12 the number and amount of fines or penalties imposed; any 13 reductions in overpayment amounts negotiated in settlement 14 agreements or by other means; the amount of final agency 15 determinations of overpayments; the amount deducted from 16 federal claiming as a result of overpayments; the amount of 17 overpayments recovered each year; the amount of cost of 18 investigation recovered each year; the average length of time 19 to collect from the time the case was opened until the 20 overpayment is paid in full; the amount determined as 21 uncollectible and the portion of the uncollectible amount 22 subsequently reclaimed from the Federal Government; the number 23 of providers, by type, that are terminated from participation 24 in the Medicaid program as a result of fraud and abuse; and 25 all costs associated with discovering and prosecuting cases of 26 Medicaid overpayments and making recoveries in such cases. The 27 report must also document actions taken to prevent 28 overpayments and the number of providers prevented from 29 enrolling in or reenrolling in the Medicaid program as a 30 result of documented Medicaid fraud and abuse and must 31 recommend changes necessary to prevent or recover 71 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 overpayments. 2 (2) The agency shall conduct, or cause to be conducted 3 by contract or otherwise, reviews, investigations, analyses, 4 audits, or any combination thereof, to determine possible 5 fraud, abuse, overpayment, or recipient neglect in the 6 Medicaid program and shall report the findings of any 7 overpayments in audit reports as appropriate. At least 5 8 percent of all audits shall be conducted on a random basis. 9 (36) The agency shall provide to each Medicaid 10 recipient or his or her representative an explanation of 11 benefits in the form of a letter that is mailed to the most 12 recent address of the recipient on the record with the 13 Department of Children and Family Services. The explanation of 14 benefits must include the patient's name, the name of the 15 health care provider and the address of the location where the 16 service was provided, a description of all services billed to 17 Medicaid in terminology that should be understood by a 18 reasonable person, and information on how to report 19 inappropriate or incorrect billing to the agency or other law 20 enforcement entities for review or investigation. 21 Section 8. The Agency for Health Care Administration 22 shall submit to the Legislature by December 15, 2005, a report 23 on the legal and administrative barriers to enforcing section 24 409.9081, Florida Statutes. The report must describe how many 25 services require copayments, which providers collect 26 copayments, and the total amount of copayments collected from 27 recipients for all services required under section 409.9081, 28 Florida Statutes, by provider type for the 2001-2002 through 29 2004-2005 fiscal years. The agency shall recommend a mechanism 30 to enforce the requirement for Medicaid recipients to make 31 copayments which does not shift the copayment amount to the 72 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 provider. The agency shall also identify the federal or state 2 laws or regulations that permit Medicaid recipients to declare 3 impoverishment in order to avoid paying the copayment and 4 extent to which these statements of impoverishment are 5 verified. If claims of impoverishment are not currently 6 verified, the agency shall recommend a system for such 7 verification. The report must also identify any other 8 cost-sharing measures that could be imposed on Medicaid 9 recipients. 10 Section 9. The Agency for Health Care Administration 11 shall submit to the Legislature by January 15, 2006, 12 recommendations to ensure that Medicaid is the payer of last 13 resort as required by section 409.910, Florida Statutes. The 14 report must identify the public and private entities that are 15 liable for primary payment of health care services and 16 recommend methods to improve enforcement of third-party 17 liability responsibility and repayment of benefits to the 18 state Medicaid program. The report must estimate the potential 19 recoveries that may be achieved through third-party liability 20 efforts if administrative and legal barriers are removed. The 21 report must recommend whether modifications to the agency's 22 contingency-fee contract for third-party liability could 23 enhance third-party liability for benefits provided to 24 Medicaid recipients. 25 Section 10. By January 15, 2006, the Office of Program 26 Policy Analysis and Government Accountability shall submit to 27 the Legislature a study of the long-term care community 28 diversion pilot project authorized under sections 29 430.701-430.709, Florida Statutes. The study may be conducted 30 by staff of the Office of Program Policy Analysis and 31 Government Accountability or by a consultant obtained through 73 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 a competitive bid pursuant to the provisions of chapter 287, 2 Florida Statutes. The study must use a statistically-valid 3 methodology to assess the percent of persons served in the 4 project over a 2-year period who would have required Medicaid 5 nursing home services without the diversion services, which 6 services are most frequently used, and which services are 7 least frequently used. The study must determine whether the 8 project is cost-effective or is an expansion of the Medicaid 9 program because a preponderance of the project enrollees would 10 not have required Medicaid nursing home services within a 11 2-year period regardless of the availability of the project or 12 that the enrollees could have been safely served through 13 another Medicaid program at a lower cost to the state. 14 Section 11. The Agency for Health Care Administration 15 shall identify how many individuals in the long-term care 16 diversion programs who receive care at home have a 17 patient-responsibility payment associated with their 18 participation in the diversion program. If no system is 19 available to assess this information, the agency shall 20 determine the cost of creating a system to identify and 21 collect these payments and whether the cost of developing a 22 system for this purpose is offset by the amount of 23 patient-responsibility payments which could be collected with 24 the system. The agency shall report this information to the 25 Legislature by December 1, 2005. 26 Section 12. The Office of Program Policy Analysis and 27 Government Accountability shall conduct a study of state 28 programs that allow non-Medicaid eligible persons under a 29 certain income level to buy into the Medicaid program as if it 30 was private insurance. The study shall examine Medicaid buy-in 31 programs in other states to determine if there are any models 74 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 that can be implemented in Florida which would provide access 2 to uninsured Floridians and what effect this program would 3 have on Medicaid expenditures based on the experience of 4 similar states. The study must also examine whether the 5 Medically Needy program could be redesigned to be a Medicaid 6 buy-in program. The study must be submitted to the Legislature 7 by January 1, 2006. 8 Section 13. The Office of Program Policy Analysis and 9 Government Accountability, in consultation with the Office of 10 Attorney General, Medicaid Fraud Control Unit and the Auditor 11 General, shall conduct a study to examine issues related to 12 the amount of state and federal dollars lost due to fraud and 13 abuse in the Medicaid prescription drug program. The study 14 shall focus on examining whether pharmaceutical manufacturers 15 and their affiliates and wholesale pharmaceutical 16 manufacturers and their affiliates that participate in the 17 Medicaid program in this state, with respect to rebates for 18 prescription drugs, are inflating the average wholesale price 19 that is used in determining how much the state pays for 20 prescription drugs for Medicaid recipients. The study shall 21 also focus on examining whether the manufacturers and their 22 affiliates are committing other deceptive pricing practices 23 with regard to federal and state rebates for prescription 24 drugs in the Medicaid program in this state. The study, 25 including findings and recommendations, shall be submitted to 26 the Governor, the President of the Senate, the Speaker of the 27 House of Representatives, the Minority Leader of the Senate, 28 and the Minority Leader of the House of Representatives by 29 January 1, 2006. 30 Section 14. The sums of $7,129,241 in recurring 31 General Revenue Funds, $9,076,875 in nonrecurring General 75 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 Revenue Funds, $8,608,242 in recurring funds from the 2 Administrative Trust Fund, and $9,076,874 in nonrecurring 3 funds from the Administrative Trust Fund are appropriated and 4 11 full time equivalent positions are authorized for the 5 purpose of implementing this act. 6 Section 15. The amendments made to section 393.0661, 7 Florida Statutes, by the Conference Committee Report on 8 Committee Substitute for Committee Substitute for Senate Bill 9 404 are repealed. 10 Section 16. The amendments made to section 409.907, 11 Florida Statutes, by the Conference Committee Report on 12 Committee Substitute for Committee Substitute for Senate Bill 13 404 are repealed. 14 Section 17. The amendments made to the introductory 15 provision only of section 409.908, Florida Statutes, by the 16 Conference Committee Report on Committee Substitute for 17 Committee Substitute for Senate Bill 404 are repealed. 18 Section 18. Section 409.9082, Florida Statutes, as 19 created by the Conference Committee Report on Committee 20 Substitute for Committee Substitute for Senate Bill 404, is 21 repealed. 22 Section 19. Section 23 of the Conference Committee 23 Report on Committee Substitute for Committee Substitute for 24 Senate Bill 404 is repealed. 25 Section 20. Subsection (2) of section 409.9124, F.S., 26 as amended by section 18 of the Conference Committee Report on 27 Committee Substitute for Committee Substitute for Senate Bill 28 404 is amended, and subsection (6) is added to that section, 29 to read: 30 409.9124 Managed care reimbursement.-- 31 (2) Each year prior to establishing new managed care 76 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 rates, the agency shall review all prior year adjustments for 2 changes in trend, and shall reduce or eliminate those 3 adjustments which are not reasonable and which reflect 4 policies or programs which are not in effect. In addition, the 5 agency shall apply only those policy reductions applicable to 6 the fiscal year for which the rates are being set, which can 7 be accurately estimated and verified by an independent 8 actuary, and which have been implemented prior to or will be 9 implemented during the fiscal year. The agency shall pay rates 10 at per-member, per-month averages that equal, but do not 11 exceed, the amounts allowed for in the General Appropriations 12 Act applicable to the fiscal year for which the rates will be 13 in effect. 14 (6) For the 2005-2006 fiscal year only, the agency 15 shall make an additional adjustment in calculating the 16 capitation payments to prepaid health plans, excluding prepaid 17 mental health plans. This adjustment must result in an 18 increase of 2.8 percent in the average per-member, per-month 19 rate paid to prepaid health plans, excluding prepaid mental 20 health plans, which are funded from Specific Appropriations 21 225 and 226 in the 2005-2006 General Appropriations Act. 22 Section 21. The Senate Select Committee on Medicaid 23 Reform shall study how provider rates are established and 24 modified, how provider agreements and administrative 25 rulemaking effect those rates, the discretion allowed by 26 federal law for the setting of rates by the state, and the 27 impact of litigation on provider rates. The committee shall 28 issue a report containing recommendations by March 1, 2006, to 29 the Governor, the President of the Senate, and the Speaker of 30 the House of Representatives. 31 Section 22. This act shall take effect July 1, 2005. 77 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 ================ T I T L E A M E N D M E N T =============== 2 And the title is amended as follows: 3 Delete everything before the enacting clause 4 5 and insert: 6 A bill to be entitled 7 An act relating to Medicaid; amending s. 8 409.912, F.S.; requiring the Agency for Health 9 Care Administration to contract with a vendor 10 to monitor and evaluate the clinical practice 11 patterns of providers; authorizing the agency 12 to competitively bid for single-source 13 providers for certain services; authorizing the 14 agency to examine whether purchasing certain 15 durable medical equipment is more 16 cost-effective than long-term rental of such 17 equipment; providing that a contract awarded to 18 a provider service network remains in effect 19 for a certain period; defining a provider 20 service network; providing health care 21 providers with a controlling interest in the 22 governing body of the provider service network 23 organization; requiring that the agency, in 24 partnership with the Department of Elderly 25 Affairs, develop an integrated, fixed-payment 26 delivery system for Medicaid recipients age 60 27 and older; requiring the Office of Program 28 Policy Analysis and Government Accountability 29 to conduct an evaluation; deleting an obsolete 30 provision requiring the agency to develop a 31 plan for implementing emergency and crisis 78 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 care; requiring the agency to develop a system 2 where health care vendors may provide a 3 business case demonstrating that higher 4 reimbursement for a good or service will be 5 offset by cost savings in other goods or 6 services; requiring the Comprehensive 7 Assessment and Review for Long-Term Care 8 Services (CARES) teams to consult with any 9 person making a determination that a nursing 10 home resident funded by Medicare is not making 11 progress toward rehabilitation and assist in 12 any appeals of the decision; requiring the 13 agency to contract with an entity to design a 14 clinical-utilization information database or 15 electronic medical record for Medicaid 16 providers; requiring the agency to coordinate 17 with other entities to create emergency room 18 diversion programs for Medicaid recipients; 19 allowing dispensing practitioners to 20 participate in Medicaid; requiring that the 21 agency implement a Medicaid 22 prescription-drug-management system; requiring 23 the agency to determine the extent that 24 prescription drugs are returned and reused in 25 institutional settings and whether this program 26 could be expanded; authorizing the agency to 27 pay for emergency mental health services 28 provided through licensed crisis-stabilization 29 facilities; creating s. 409.91211, F.S.; 30 specifying waiver authority for the Agency for 31 Health Care Administration to establish a 79 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 Medicaid reform program contingent on federal 2 approval to preserve the upper-payment-limit 3 finding mechanism for hospitals and contingent 4 on protection of the disproportionate share 5 program authorized pursuant to ch. 409, F.S.; 6 providing legislative intent; providing powers, 7 duties, and responsibilities of the agency 8 under the pilot program; requiring that the 9 agency submit any waivers to the Legislature 10 for approval before implementation; allowing 11 the agency to develop rules; requiring that the 12 Office of Program Policy Analysis and 13 Government Accountability, in consultation with 14 the Auditor General, evaluate the pilot program 15 and report to the Governor and the Legislature 16 on whether it should be expanded statewide; 17 amending s. 409.9062, F.S.; requiring the 18 Agency for Health Care Administration to 19 reimburse lung transplant facilities a global 20 fee for services provided to Medicaid 21 recipients; providing an appropriation; 22 amending s. 409.9122, F.S.; revising a 23 reference; amending s. 409.913, F.S.; requiring 24 5 percent of all program integrity audits to be 25 conducted on a random basis; requiring that 26 Medicaid recipients be provided with an 27 explanation of benefits; requiring that the 28 agency report to the Legislature on the legal 29 and administrative barriers to enforcing the 30 copayment requirements of s. 409.9081, F.S.; 31 requiring the agency to recommend ways to 80 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 ensure that Medicaid is the payer of last 2 resort; requiring the Office of Program Policy 3 Analysis and Government Accountability to 4 conduct a study of the long-term care diversion 5 programs; requiring the agency to determine how 6 many individuals in long-term care diversion 7 programs have a patient payment responsibility 8 that is not being collected and to recommend 9 how to collect such payments; requiring the 10 Office of Program Policy Analysis and 11 Government Accountability to conduct a study of 12 Medicaid buy-in programs to determine if these 13 programs can be created in this state without 14 expanding the overall Medicaid program budget 15 or if the Medically Needy program can be 16 changed into a Medicaid buy-in program; 17 providing an appropriation and authorizing 18 positions to implement this act; requiring the 19 Office of Program Policy Analysis and 20 Government Accountability, in consultation with 21 the Office of Attorney General and the Auditor 22 General, to conduct a study to examine whether 23 state and federal dollars are lost due to fraud 24 and abuse in the Medicaid prescription drug 25 program; providing duties; requiring that a 26 report with findings and recommendations be 27 submitted to the Governor and the Legislature 28 by a specified date; repealing the amendments 29 made to ss. 393.0661, 409.907, and 409.9082, 30 F.S., and the amendments made to the 31 introductory provision of s. 409.908, F.S., by 81 6:35 PM 05/06/05 s0838e1c-02-j32
Florida Senate - 2005 SENATOR AMENDMENT Bill No. CS for CS for SB 838, 1st Eng. Barcode 653330 1 the Conference Committee Report on CS for CS 2 for SB 404, relating to provider agreements and 3 provider methodologies; repealing s. 23 of the 4 Conference Committee Report on CS for CS for SB 5 404, relating to legislative intent; amending 6 s. 409.9124, F.S., as amended by the Conference 7 Committee Report on CS for CS for SB 404; 8 revising provisions requiring the Agency for 9 Health Care Administration to pay certain rates 10 for managed care reimbursement; requiring that 11 the agency make an additional adjustment in 12 calculating the rates paid to prepaid health 13 plans for the 2005-2006 fiscal year; requiring 14 that the Senate Select Committee on Medicaid 15 Reform study various issues concerning Medicaid 16 provider rates and issue a report to the 17 Governor and the Legislature; providing an 18 effective date. 19 20 21 22 23 24 25 26 27 28 29 30 31 82 6:35 PM 05/06/05 s0838e1c-02-j32

Disclaimer: The information on this system is unverified. The journals or printed bills of the respective chambers should be consulted for official purposes. Copyright © 2000-2021 State of Florida.