Bill Text: FL H7225 | 2010 | Regular Session | Engrossed

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Bill Title: Medicaid

Spectrum: Partisan Bill (Republican 1-0)

Status: (Failed) 2010-04-30 - Died in Messages, companion bill(s) passed, see HB 5301 (Ch. 2010-156), HB 5303 (Ch. 2010-157), CS/CS/SB 1484 (Ch. 2010-144) [H7225 Detail]

Download: Florida-2010-H7225-Engrossed.html

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HB 7225

1	A bill to be entitled
2	An act relating to Medicaid; amending s. 393.0661, F.S.,
3	relating to the home and community-based services delivery
4	system for persons with developmental disabilities;
5	providing for an establishment of an iBudget demonstration
6	project by the Agency for Persons with Disabilities, in
7	consultation with the Agency for Health Care
8	Administration, in specified counties; providing for
9	allocation of funds; providing goals; providing for an
10	allocation algorithm and methodology for development of a
11	client's iBudget; providing for the seeking of federal
12	approval and waivers; providing for a transition to full
13	implementation; providing for inapplicability of certain
14	service limitations; providing for setting rates;
15	providing for client training and education; providing for
16	evaluation; requiring a report; requiring rulemaking;
17	requiring the Agency for Persons with Disabilities to
18	establish a transition plan for current Medicaid
19	recipients under certain circumstances; providing for
20	expiration of the section on a specified date; creating s.
21	400.0713, F.S.; requiring the Agency for Health Care
22	Administration to establish a nursing home licensure
23	workgroup; amending s. 408.040, F.S.; providing for
24	suspension of conditions precedent to the issuance of a
25	certificate of need for a nursing home, effective on a
26	specified date; amending s. 408.0435, F.S.; extending the
27	certificate-of-need moratorium for additional community
28	nursing home beds; designating ss. 409.016-409.803, F.S.,
29	as pt. I of ch. 409, F.S., and entitling the part "Social
30	and Economic Assistance"; designating ss. 409.810-409.821,
31	F.S., as pt. II of ch. 409, F.S., and entitling the part
32	"Kidcare"; designating ss. 409.901-409.9205, F.S., as part
33	III of ch. 409, F.S., and entitling the part "Medicaid";
34	amending s. 409.907, F.S.; authorizing the Agency for
35	Health Care Administration to enroll entities as Medicare
36	crossover-only providers for payment and claims processing
37	purposes only; specifying requirements for Medicare
38	crossover-only agreements; amending s. 409.908, F.S.;
39	providing penalties for providers that fail to report
40	suspension or disenrollment from Medicare within a
41	specified time; amending s. 409.912, F.S.; authorizing
42	provider service networks to provide comprehensive
43	behavioral health care services to certain Medicaid
44	recipients; providing payment requirements for provider
45	service networks; providing for the expiration of various
46	provisions of the section on specified dates to conform to
47	the reorganization of Medicaid managed care; requiring the
48	Agency for Health Care Administration to contract on a
49	prepaid or fixed-sum basis with certain prepaid dental
50	health plans; requiring Medicaid-eligible children with
51	open child welfare cases who reside in AHCA area 10 to be
52	enrolled in specified capitated managed care plans;
53	eliminating obsolete provisions and updating provisions
54	within the section; amending ss. 409.91195 and 409.91196,
55	F.S.; conforming cross-references; amending s. 409.91207,
56	F.S.; providing authority of the Agency for Health Care
57	Administration with respect to the development of a method
58	for designating qualified plans as a medical home network;
59	providing purposes and principles for creating medical
60	home networks; providing criteria for designation of a
61	qualified plan as a medical home network; providing agency
62	duties with respect thereto; amending s. 409.91211, F.S.;
63	providing authority of the Agency for Health Care
64	Administration to implement a managed care pilot program
65	based on specified waiver authority with respect to the
66	Medicaid reform program; continuing the existing pilot
67	program in specified counties; requiring the agency to
68	seek an extension of the waiver; providing for monthly
69	reports; requiring approval of the Legislative Budget
70	Commission for changes to specified terms and conditions ;
71	providing for expansion of the managed care pilot program
72	to Miami-Dade County; specifying managed care plans that
73	are qualified to participate in the Medicaid managed care
74	pilot program; providing requirements for qualified
75	managed care plans; requiring the agency to develop and
76	seek federal approval to implement methodologies to
77	preserve intergovernmental transfers of funds and
78	certified public expenditures from Miami-Dade County;
79	requiring the agency to submit a plan and specified
80	amendment to the Legislative Budget Commission; providing
81	for a report; requiring Medicaid recipients in counties in
82	which the managed care pilot program has been implemented
83	to be enrolled in a qualified plan; providing a time limit
84	for enrollment; requiring the agency to provide choice
85	counseling; providing requirements with respect to choice
86	counseling information provided to Medicaid recipients;
87	providing for automatic enrollment of certain Medicaid
88	recipients; establishing criteria for automatic
89	enrollment; providing procedures and requirements with
90	respect to voluntary disenrollment of a recipient in a
91	qualified plan; providing for an enrollment period;
92	requiring qualified plans to establish a process for
93	review of and response to grievances of enrollees;
94	requiring qualified plans to submit quarterly reports;
95	specifying services to be covered by qualified plans;
96	authorizing qualified plans to offer specified
97	customizations, variances, and coverage for additional
98	services; requiring agency evaluation of proposed benefit
99	packages; requiring qualified plans to reimburse the
100	agency for the cost of specified enrollment changes;
101	providing for access to encounter data; requiring
102	participating plans to establish an incentive program to
103	reward healthy behaviors; requiring the agency to continue
104	budget-neutral adjustment of capitation rates for all
105	prepaid plans in existing managed care pilot program
106	counties; providing for transition to payment
107	methodologies for Miami-Dade County plans; providing a
108	phased schedule for risk-adjusted capitation rates;
109	providing for immediate risk adjustment of rates for plans
110	owned and operated by a public hospital in the county;
111	providing a method to ensure budget neutrality until all
112	rates in the county are risk-adjusted; requiring the
113	agency to submit an amendment to the Legislative Budget
114	Commission requesting authority for payments; requiring
115	the establishment of a technical advisory panel; providing
116	for distribution of funds from a low-income pool;
117	specifying purposes for such distribution; requiring the
118	agency to maintain and operate the Medicaid Encounter Data
119	System; requiring the agency to contract with the
120	University of Florida for evaluation of the pilot program;
121	requiring the agency to establish a specified initiative
122	and publish certain information; amending s. 409.9122,
123	F.S.; eliminating outdated provisions; providing for the
124	expiration of various provisions of the section on
125	specified dates to conform to the reorganization of
126	Medicaid managed care; requiring the Agency for Health
127	Care Administration to begin a budget-neutral adjustment
128	of capitation rates for all Medicaid prepaid plans in the
129	state on a specified date; providing the basis for the
130	adjustment; providing a phased schedule for risk adjusted
131	capitation rates; providing for the establishment of a
132	technical advisory panel; requiring the agency to develop
133	a process to enable any recipient with access to employer
134	sponsored insurance to opt out of qualified plans in the
135	Medicaid program; requiring the agency, contingent on
136	federal approval, to enable recipients with access to
137	other insurance or related products providing access to
138	specified health care services to opt out of qualified
139	plans in the Medicaid program; providing a limitation on
140	the amount of financial assistance provided for each
141	recipient; requiring each qualified plan to establish an
142	incentive program that rewards specific healthy behaviors;
143	requiring plans to maintain a specified reserve account;
144	requiring the agency to maintain and operate the Medicaid
145	Encounter Data System; requiring the agency to conduct a
146	review of encounter data and publish the results of the
147	review prior to adjusting rates for prepaid plans;
148	requiring the agency to establish a designated payment for
149	specified Medicare Advantage Special Needs members;
150	authorizing the agency to develop a designated payment for
151	Medicaid-only covered services for which the state is
152	responsible; requiring the agency to establish, and
153	managed care plans to use, a uniform method of accounting
154	for and reporting of medical and nonmedical costs;
155	requiring reimbursement by Medicaid of school districts
156	participating in a certified school match program for a
157	Medicaid-eligible child participating in the services,
158	effective on a specified date; requiring the agency, the
159	Department of Health, and the Department of Education to
160	develop procedures for ensuring that a student's managed
161	care plan receives information relating to services
162	provided; authorizing the Agency for Health Care
163	Administration to create exceptions to mandatory
164	enrollment in managed care under specified circumstances;
165	amending s. 430.04, F.S.; eliminating outdated provisions;
166	requiring the Department of Elderly Affairs to develop a
167	transition plan for specified elder and disabled adults
168	receiving long-term care Medicaid services when qualified
169	plans become available; providing for expiration thereof;
170	amending s. 430.2053, F.S.; eliminating outdated
171	provisions; providing additional duties of aging resource
172	centers; providing an additional exception to direct
173	services that may not be provided by an aging resource
174	center; providing for the cessation of specified payments
175	by the department as qualified plans become available;
176	providing for a memorandum of understanding between the
177	Agency for Health Care Administration and aging resource
178	centers under certain circumstances; eliminating
179	provisions requiring reports; amending s. 641.386, F.S.;
180	conforming a cross-reference; repealing s. 430.701, F.S.,
181	relating to legislative findings and intent and approval
182	for action relating to provider enrollment levels;
183	repealing s. 430.702, F.S., relating to the Long-Term Care
184	Community Diversion Pilot Project Act; repealing s.
185	430.703, F.S., relating to definitions; repealing s.
186	430.7031, F.S., relating to nursing home transition
187	program; repealing s. 430.704, F.S., relating to
188	evaluation of long-term care through the pilot projects;
189	repealing s. 430.705, F.S., relating to implementation of
190	long-term care community diversion pilot projects;
191	repealing s. 430.706, F.S., relating to quality of care;
192	repealing s. 430.707, F.S., relating to contracts;
193	repealing s. 430.708, F.S., relating to certificate of
194	need; repealing s. 430.709, F.S., relating to reports and
195	evaluations; renumbering ss. 409.9301, 409.942, 409.944,
196	409.945, 409.946, 409.953, and 409.9531, F.S., as ss.
197	402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
198	402.87, F.S., respectively; amending s. 443.111, F.S.;
199	conforming a cross-reference; providing contingent
200	effective dates.
201
202	Be It Enacted by the Legislature of the State of Florida:
203
204	Section 1. Section 393.0661, Florida Statutes, is amended
205	to read:
206	393.0661 Home and community-based services delivery
207	system; comprehensive redesign.-The Legislature finds that the
208	home and community-based services delivery system for persons
209	with developmental disabilities and the availability of
210	appropriated funds are two of the critical elements in making
211	services available. Therefore, it is the intent of the
212	Legislature that the Agency for Persons with Disabilities shall
213	develop and implement a comprehensive redesign of the system.
214	(1) The redesign of the home and community-based services
215	system shall include, at a minimum, all actions necessary to
216	achieve an appropriate rate structure, client choice within a
217	specified service package, appropriate assessment strategies, an
218	efficient billing process that contains reconciliation and
219	monitoring components, a redefined role for support coordinators
220	that avoids potential conflicts of interest, and ensures that
221	family/client budgets are linked to levels of need.
222	(a) The agency shall use an assessment instrument that is
223	reliable and valid. The agency may contract with an external
224	vendor or may use support coordinators to complete client
225	assessments if it develops sufficient safeguards and training to
226	ensure ongoing inter-rater reliability.
227	(b) The agency, with the concurrence of the Agency for
228	Health Care Administration, may contract for the determination
229	of medical necessity and establishment of individual budgets.
230	(2) A provider of services rendered to persons with
231	developmental disabilities pursuant to a federally approved
232	waiver shall be reimbursed according to a rate methodology based
233	upon an analysis of the expenditure history and prospective
234	costs of providers participating in the waiver program, or under
235	any other methodology developed by the Agency for Health Care
236	Administration, in consultation with the Agency for Persons with
237	Disabilities, and approved by the Federal Government in
238	accordance with the waiver.
239	(3) The Agency for Health Care Administration, in
240	consultation with the agency, shall seek federal approval and
241	implement a four-tiered waiver system to serve eligible clients
242	through the developmental disabilities and family and supported
243	living waivers. The agency shall assign all clients receiving
244	services through the developmental disabilities waiver to a tier
245	based on a valid assessment instrument, client characteristics,
246	and other appropriate assessment methods.
247	(a) Tier one is limited to clients who have service needs
248	that cannot be met in tier two, three, or four for intensive
249	medical or adaptive needs and that are essential for avoiding
250	institutionalization, or who possess behavioral problems that
251	are exceptional in intensity, duration, or frequency and present
252	a substantial risk of harm to themselves or others.
253	(b) Tier two is limited to clients whose service needs
254	include a licensed residential facility and who are authorized
255	to receive a moderate level of support for standard residential
256	habilitation services or a minimal level of support for behavior
257	focus residential habilitation services, or clients in supported
258	living who receive more than 6 hours a day of in-home support
259	services. Total annual expenditures under tier two may not
260	exceed $55,000 per client each year.
261	(c) Tier three includes, but is not limited to, clients
262	requiring residential placements, clients in independent or
263	supported living situations, and clients who live in their
264	family home. Total annual expenditures under tier three may not
265	exceed $35,000 per client each year.
266	(d) Tier four is the family and supported living waiver
267	and includes, but is not limited to, clients in independent or
268	supported living situations and clients who live in their family
269	home. Total annual expenditures under tier four may not exceed
270	$14,792 per client each year.
271	(e) The Agency for Health Care Administration shall also
272	seek federal approval to provide a consumer-directed option for
273	persons with developmental disabilities which corresponds to the
274	funding levels in each of the waiver tiers. The agency shall
275	implement the four-tiered waiver system beginning with tiers
276	one, three, and four and followed by tier two. The agency and
277	the Agency for Health Care Administration may adopt rules
278	necessary to administer this subsection.
279	(f) The agency shall seek federal waivers and amend
280	contracts as necessary to make changes to services defined in
281	federal waiver programs administered by the agency as follows:
282	1. Supported living coaching services may not exceed 20
283	hours per month for persons who also receive in-home support
284	services.
285	2. Limited support coordination services is the only type
286	of support coordination service that may be provided to persons
287	under the age of 18 who live in the family home.
288	3. Personal care assistance services are limited to 180
289	hours per calendar month and may not include rate modifiers.
290	Additional hours may be authorized for persons who have
291	intensive physical, medical, or adaptive needs if such hours are
292	essential for avoiding institutionalization.
293	4. Residential habilitation services are limited to 8
294	hours per day. Additional hours may be authorized for persons
295	who have intensive medical or adaptive needs and if such hours
296	are essential for avoiding institutionalization, or for persons
297	who possess behavioral problems that are exceptional in
298	intensity, duration, or frequency and present a substantial risk
299	of harming themselves or others. This restriction shall be in
300	effect until the four-tiered waiver system is fully implemented.
301	5. Chore services, nonresidential support services, and
302	homemaker services are eliminated. The agency shall expand the
303	definition of in-home support services to allow the service
304	provider to include activities previously provided in these
305	eliminated services.
306	6. Massage therapy, medication review, and psychological
307	assessment services are eliminated.
308	7. The agency shall conduct supplemental cost plan reviews
309	to verify the medical necessity of authorized services for plans
310	that have increased by more than 8 percent during either of the
311	2 preceding fiscal years.
312	8. The agency shall implement a consolidated residential
313	habilitation rate structure to increase savings to the state
314	through a more cost-effective payment method and establish
315	uniform rates for intensive behavioral residential habilitation
316	services.
317	9. Pending federal approval, the agency may extend current
318	support plans for clients receiving services under Medicaid
319	waivers for 1 year beginning July 1, 2007, or from the date
320	approved, whichever is later. Clients who have a substantial
321	change in circumstances which threatens their health and safety
322	may be reassessed during this year in order to determine the
323	necessity for a change in their support plan.
324	10. The agency shall develop a plan to eliminate
325	redundancies and duplications between in-home support services,
326	companion services, personal care services, and supported living
327	coaching by limiting or consolidating such services.
328	11. The agency shall develop a plan to reduce the
329	intensity and frequency of supported employment services to
330	clients in stable employment situations who have a documented
331	history of at least 3 years' employment with the same company or
332	in the same industry.
333	(4) The geographic differential for Miami-Dade, Broward,
334	and Palm Beach Counties for residential habilitation services
335	shall be 7.5 percent.
336	(5) The geographic differential for Monroe County for
337	residential habilitation services shall be 20 percent.
338	(6) Effective January 1, 2010, and except as otherwise
339	provided in this section, a client served by the home and
340	community-based services waiver or the family and supported
341	living waiver funded through the agency shall have his or her
342	cost plan adjusted to reflect the amount of expenditures for the
343	previous state fiscal year plus 5 percent if such amount is less
344	than the client's existing cost plan. The agency shall use
345	actual paid claims for services provided during the previous
346	fiscal year that are submitted by October 31 to calculate the
347	revised cost plan amount. If the client was not served for the
348	entire previous state fiscal year or there was any single change
349	in the cost plan amount of more than 5 percent during the
350	previous state fiscal year, the agency shall set the cost plan
351	amount at an estimated annualized expenditure amount plus 5
352	percent. The agency shall estimate the annualized expenditure
353	amount by calculating the average of monthly expenditures,
354	beginning in the fourth month after the client enrolled,
355	interrupted services are resumed, or the cost plan was changed
356	by more than 5 percent and ending on August 31, 2009, and
357	multiplying the average by 12. In order to determine whether a
358	client was not served for the entire year, the agency shall
359	include any interruption of a waiver-funded service or services
360	lasting at least 18 days. If at least 3 months of actual
361	expenditure data are not available to estimate annualized
362	expenditures, the agency may not rebase a cost plan pursuant to
363	this subsection. The agency may not rebase the cost plan of any
364	client who experiences a significant change in recipient
365	condition or circumstance which results in a change of more than
366	5 percent to his or her cost plan between July 1 and the date
367	that a rebased cost plan would take effect pursuant to this
368	subsection.
369	(7) Nothing in this section or in any administrative rule
370	shall be construed to prevent or limit the Agency for Health
371	Care Administration, in consultation with the Agency for Persons
372	with Disabilities, from adjusting fees, reimbursement rates,
373	lengths of stay, number of visits, or number of services, or
374	from limiting enrollment, or making any other adjustment
375	necessary to comply with the availability of moneys and any
376	limitations or directions provided for in the General
377	Appropriations Act.
378	(8) The Agency for Persons with Disabilities shall submit
379	quarterly status reports to the Executive Office of the
380	Governor, the chair of the Senate Ways and Means Committee or
381	its successor, and the chair of the House Fiscal Council or its
382	successor regarding the financial status of home and community-
383	based services, including the number of enrolled individuals who
384	are receiving services through one or more programs; the number
385	of individuals who have requested services who are not enrolled
386	but who are receiving services through one or more programs,
387	with a description indicating the programs from which the
388	individual is receiving services; the number of individuals who
389	have refused an offer of services but who choose to remain on
390	the list of individuals waiting for services; the number of
391	individuals who have requested services but who are receiving no
392	services; a frequency distribution indicating the length of time
393	individuals have been waiting for services; and information
394	concerning the actual and projected costs compared to the amount
395	of the appropriation available to the program and any projected
396	surpluses or deficits. If at any time an analysis by the agency,
397	in consultation with the Agency for Health Care Administration,
398	indicates that the cost of services is expected to exceed the
399	amount appropriated, the agency shall submit a plan in
400	accordance with subsection (7) to the Executive Office of the
401	Governor, the chair of the Senate Ways and Means Committee or
402	its successor, and the chair of the House Fiscal Council or its
403	successor to remain within the amount appropriated. The agency
404	shall work with the Agency for Health Care Administration to
405	implement the plan so as to remain within the appropriation.
406	(9)(a) The agency, in consultation with the Agency for
407	Health Care Administration, shall establish an individual
408	budget, referred to as an iBudget, demonstration project for
409	each individual served through the Medicaid waiver program in
410	Escambia, Okaloosa, Santa Rosa, and Walton Counties, which
411	comprise area one of the agency. For the purpose of this
412	subsection, the Medicaid waiver program includes the four-tiered
413	waiver system established in subsection (3) or the Consumer
414	Directed Care Plus Medicaid waiver program. The funds
415	appropriated to the agency and used for Medicaid waiver program
416	services to individuals in the demonstration project area shall
417	be allocated through the iBudget system to eligible, Medicaid-
418	enrolled clients. The iBudget system shall be designed to
419	provide for enhanced client choice within a specified service
420	package, appropriate assessment strategies, an efficient
421	consumer budgeting and billing process that includes
422	reconciliation and monitoring components, a redefined role for
423	support coordinators that avoids potential conflicts of
424	interest, a flexible and streamlined service review process, and
425	a methodology and process that ensure the equitable allocation
426	of available funds to each client based on the client's level of
427	need, as determined by the variables in the allocation
428	algorithm.
429	1. In developing each client's iBudget, the agency shall
430	use an allocation algorithm and methodology. The algorithm shall
431	use variables that have been determined by the agency to have a
432	statistically validated relationship to the client's level of
433	need for services provided through the Medicaid waiver program.
434	The algorithm and methodology may consider individual
435	characteristics, including, but not limited to, a client's age
436	and living situation, information from a formal assessment
437	instrument that the agency determines is valid and reliable, and
438	information from other assessment processes.
439	2. The allocation methodology shall provide the algorithm
440	that determines the amount of funds allocated to a client's
441	iBudget. The agency may approve an increase in the amount of
442	funds allocated, as determined by the algorithm, based on the
443	client's having one or more of the following needs that cannot
444	be accommodated within the funding as determined by the
445	algorithm and having no other resources, supports, or services
446	available to meet those needs:
447	a. An extraordinary need that would place the health and
448	safety of the client, the client's caregiver, or the public in
449	immediate, serious jeopardy unless the increase is approved. An
450	extraordinary need may include, but is not limited to:
451	(I) A documented history of significant, potentially life-
452	threatening behaviors, such as recent attempts at suicide,
453	arson, nonconsensual sexual behavior, or self-injurious behavior
454	requiring medical attention;
455	(II) A complex medical condition that requires active
456	intervention by a licensed nurse on an ongoing basis that cannot
457	be taught or delegated to a nonlicensed person;
458	(III) A chronic co-morbid condition. As used in this sub-
459	sub-subparagraph, the term "co-morbid condition" means a medical
460	condition existing simultaneously with but independently of
461	another medical condition in a patient; or
462	(IV) A need for total physical assistance with activities
463	such as eating, bathing, toileting, grooming, and personal
464	hygiene.
465
466	However, the presence of an extraordinary need alone does not
467	warrant an increase in the amount of funds allocated to a
468	client's iBudget as determined by the algorithm.
469	b. A significant need for one-time or temporary support or
470	services that, if not provided, would place the health and
471	safety of the client, the client's caregiver, or the public in
472	serious jeopardy unless the increase is approved. A significant
473	need may include, but is not limited to, the provision of
474	environmental modifications, durable medical equipment, services
475	to address the temporary loss of support from a caregiver, or
476	special services or treatment for a serious temporary condition
477	when the service or treatment is expected to ameliorate the
478	underlying condition. As used in this sub-subparagraph, the term
479	"temporary" means lasting for a period of less than 12
480	consecutive months. However, the presence of such significant
481	need for one-time or temporary support or services alone does
482	not warrant an increase in the amount of funds allocated to a
483	client's iBudget as determined by the algorithm.
484	c. A significant increase in the need for services after
485	the beginning of the service plan year that would place the
486	health and safety of the client, the client's caregiver, or the
487	public in serious jeopardy because of substantial changes in the
488	client's circumstances, including, but not limited to, permanent
489	or long-term loss or incapacity of a caregiver, loss of services
490	authorized under the state Medicaid plan due to a change in age,
491	or a significant change in medical or functional status that
492	requires the provision of additional services on a permanent or
493	long-term basis that cannot be accommodated within the client's
494	current iBudget. As used in this sub-subparagraph, the term
495	"long-term" means lasting for a period of more than 12
496	continuous months. However, such significant increase in need
497	for services of a permanent or long-term nature alone does not
498	warrant an increase in the amount of funds allocated to a
499	client's iBudget as determined by the algorithm.
500
501	The agency shall reserve portions of the appropriation for the
502	home and community-based services Medicaid waiver program for
503	adjustments required pursuant to this subparagraph and may use
504	the services of an independent actuary in determining the amount
505	of the portions to be reserved.
506	3. A client's iBudget shall be the total of the amount
507	determined by the algorithm and any additional funding provided
508	under subparagraph 2. A client's annual expenditures for
509	Medicaid waiver services may not exceed the limits of his or her
510	iBudget.
511	(b) The Agency for Health Care Administration, in
512	consultation with the agency, shall seek federal approval for
513	the iBudget demonstration project and amend current waivers,
514	request a new waiver if appropriate, and amend contracts as
515	necessary to implement the iBudget system to serve eligible,
516	enrolled clients in the demonstration project area through the
517	Medicaid waiver program.
518	(c) The agency shall transition all eligible, enrolled
519	clients in the demonstration project area to the iBudget system.
520	The agency may gradually phase in the iBudget system with full
521	implementation by January 1, 2013.
522	1. The agency shall design the phase-in process to ensure
523	that a client does not experience more than one-half of any
524	expected overall increase or decrease to his or her existing
525	annualized cost plan during the first year that the client is
526	provided an iBudget due solely to the transition to the iBudget
527	system. However, all iBudgets in the demonstration project area
528	must be fully phased in by January 1, 2013.
529	(d) A client must use all available services authorized
530	under the state Medicaid plan, school-based services, private
531	insurance and other benefits, and any other resources that may
532	be available to the client before using funds from his or her
533	iBudget to pay for support and services.
534	(e) The service limitations in subparagraphs (3)(f)1., 2.,
535	and 3. shall not apply to the iBudget system.
536	(f) Rates for any or all services established under rules
537	of the agency shall be designated as the maximum rather than a
538	fixed amount for individuals who receive an iBudget, except for
539	services specifically identified in those rules that the agency
540	determines are not appropriate for negotiation, which may
541	include, but are not limited to, residential habilitation
542	services.
543	(g) The agency shall ensure that clients and caregivers in
544	the demonstration project area have access to training and
545	education to inform them about the iBudget system and enhance
546	their ability for self-direction. Such training shall be offered
547	in a variety of formats and, at a minimum, shall address the
548	policies and processes of the iBudget system; the roles and
549	responsibilities of consumers, caregivers, waiver support
550	coordinators, providers, and the agency; information available
551	to help the client make decisions regarding the iBudget system;
552	and examples of support and resources available in the
553	community.
554	(h)1. The agency, in consultation with the Agency for
555	Health Care Administration, shall prepare a design plan for the
556	purchase of an evaluation by an independent contractor. The
557	design plan to evaluate the iBudget demonstration project shall
558	be submitted to the President of the Senate and the Speaker of
559	the House of Representatives for approval not later than
560	December 31, 2010.
561	2. The agency shall prepare an evaluation that shall
562	include, at a minimum, an analysis of cost savings, cost
563	containment, and budget predictability. In addition, the
564	evaluation shall review the demonstration with regard to
565	consumer education, quality of care, affects on choice of and
566	access to services, and satisfaction of demonstration project
567	participants. The agency shall submit the evaluation report to
568	the Governor, the President of the Senate, and the Speaker of
569	the House of Representatives no later than December 31, 2013.
570	(i) The agency shall adopt rules specifying the allocation
571	algorithm and methodology; criteria and processes for clients to
572	access reserved funds for extraordinary needs, temporarily or
573	permanently changed needs, and one-time needs; and processes and
574	requirements for selection and review of services, development
575	of support and cost plans, and management of the iBudget system
576	as needed to administer this subsection.
577	(10) The agency shall develop a transition plan for
578	recipients who are receiving services in one of the four waiver
579	tiers at the time qualified plans are available in each
580	recipient's region pursuant to s. 409.989(3) to enroll those
581	recipients in qualified plans.
582	(11) This section expires October 1, 2015.
583	Section 2. Section 400.0713, Florida Statutes, is created
584	to read:
585	400.0713 Nursing home licensure workgroup.-The agency
586	shall establish a workgroup to develop a plan for licensure
587	flexibility to assist nursing homes in developing comprehensive
588	long-term care service capabilities.
589	Section 3. Paragraphs (b) and (d) of subsection (1) of
590	section 408.040, Florida Statutes, are amended to read:
591	408.040 Conditions and monitoring.-
592	(1)
593	(b) The agency may consider, in addition to the other
594	criteria specified in s. 408.035, a statement of intent by the
595	applicant that a specified percentage of the annual patient days
596	at the facility will be utilized by patients eligible for care
597	under Title XIX of the Social Security Act. Any certificate of
598	need issued to a nursing home in reliance upon an applicant's
599	statements that a specified percentage of annual patient days
600	will be utilized by residents eligible for care under Title XIX
601	of the Social Security Act must include a statement that such
602	certification is a condition of issuance of the certificate of
603	need. The certificate-of-need program shall notify the Medicaid
604	program office and the Department of Elderly Affairs when it
605	imposes conditions as authorized in this paragraph in an area in
606	which a community diversion pilot project is implemented.
607	Effective July 1, 2011, the agency shall not consider, or impose
608	conditions related to, patient day utilization by patients
609	eligible for care under Title XIX the Social Security Act in
610	making certificate-of-need determinations for nursing homes.
611	(d) If a nursing home is located in a county in which a
612	long-term care community diversion pilot project has been
613	implemented under s. 430.705 or in a county in which an
614	integrated, fixed-payment delivery program for Medicaid
615	recipients who are 60 years of age or older or dually eligible
616	for Medicare and Medicaid has been implemented under s.
617	409.912(5), the nursing home may request a reduction in the
618	percentage of annual patient days used by residents who are
619	eligible for care under Title XIX of the Social Security Act,
620	which is a condition of the nursing home's certificate of need.
621	The agency shall automatically grant the nursing home's request
622	if the reduction is not more than 15 percent of the nursing
623	home's annual Medicaid-patient-days condition. A nursing home
624	may submit only one request every 2 years for an automatic
625	reduction. A requesting nursing home must notify the agency in
626	writing at least 60 days in advance of its intent to reduce its
627	annual Medicaid-patient-days condition by not more than 15
628	percent. The agency must acknowledge the request in writing and
629	must change its records to reflect the revised certificate-of-
630	need condition. This paragraph expires June 30, 2011.
631	Section 4. Subsection (1) of section 408.0435, Florida
632	Statutes, is amended to read:
633	408.0435 Moratorium on nursing home certificates of need.-
634	(1) Notwithstanding the establishment of need as provided
635	for in this chapter, a certificate of need for additional
636	community nursing home beds may not be approved by the agency
637	until after Medicaid managed care is implemented statewide
638	pursuant to ss. 409.961-409.992, or October 1, 2015, whichever
639	is earlier July 1, 2011.
640	Section 5. Sections 409.016 through 409.803, Florida
641	Statutes, are designated as part I of chapter 409, Florida
642	Statutes, and entitled "SOCIAL AND ECONOMIC ASSISTANCE."
643	Section 6. Sections 409.810 through 409.821, Florida
644	Statutes, are designated as part II of chapter 409, Florida
645	Statutes, and entitled "KIDCARE."
646	Section 7. Sections 409.901 through 409.9205, Florida
647	Statutes, are designated as part III of chapter 409, Florida
648	Statutes, and entitled "MEDICAID."
649	Section 8. Subsection (5) of section 409.907, Florida
650	Statutes, is amended to read:
651	409.907 Medicaid provider agreements.-The agency may make
652	payments for medical assistance and related services rendered to
653	Medicaid recipients only to an individual or entity who has a
654	provider agreement in effect with the agency, who is performing
655	services or supplying goods in accordance with federal, state,
656	and local law, and who agrees that no person shall, on the
657	grounds of handicap, race, color, or national origin, or for any
658	other reason, be subjected to discrimination under any program
659	or activity for which the provider receives payment from the
660	agency.
661	(5) The agency:
662	(a) Is required to make timely payment at the established
663	rate for services or goods furnished to a recipient by the
664	provider upon receipt of a properly completed claim form. The
665	claim form shall require certification that the services or
666	goods have been completely furnished to the recipient and that,
667	with the exception of those services or goods specified by the
668	agency, the amount billed does not exceed the provider's usual
669	and customary charge for the same services or goods.
670	(b) Is prohibited from demanding repayment from the
671	provider in any instance in which the Medicaid overpayment is
672	attributable to error of the department in the determination of
673	eligibility of a recipient.
674	(c) May adopt, and include in the provider agreement, such
675	other requirements and stipulations on either party as the
676	agency finds necessary to properly and efficiently administer
677	the Medicaid program.
678	(d) May enroll entities as Medicare crossover-only
679	providers for payment and claims processing purposes only. The
680	provider agreement shall:
681	1. Require that the provider is an eligible Medicare
682	provider, has a current provider agreement in place with the
683	Centers for Medicare and Medicaid Services, and provides
684	verification that the provider is currently in good standing
685	with the agency.
686	2. Require that the provider notify the agency
687	immediately, in writing, upon being suspended or disenrolled as
688	a Medicare provider. If a provider does not provide such
689	notification within 5 business days after suspension or
690	disenrollment, sanctions may be imposed pursuant to this chapter
691	and the provider may be required to return funds paid to the
692	provider during the period of time that the provider was
693	suspended or disenrolled as a Medicare provider.
694	3. Require that all records pertaining to health care
695	services provided to each of the provider's recipients be kept
696	for a minimum of 5 years. The agreement shall also require that
697	records and information relating to payments claimed by the
698	provider for services under the agreement be delivered to the
699	agency or the Office of the Attorney General Medicaid Fraud
700	Control Unit when requested. If a provider does not provide such
701	records and information when requested, sanctions may be imposed
702	pursuant to this chapter.
703	4. Disclose that the agreement is for the purposes of
704	paying and processing Medicare crossover claims only.
705
706	This paragraph pertains solely to Medicare crossover-only
707	providers. In order to become a standard Medicaid provider, the
708	other requirements of this section and applicable rules must be
709	met.
710	Section 9. Subsection (24) is added to section 409.908,
711	Florida Statutes, to read:
712	409.908 Reimbursement of Medicaid providers.-Subject to
713	specific appropriations, the agency shall reimburse Medicaid
714	providers, in accordance with state and federal law, according
715	to methodologies set forth in the rules of the agency and in
716	policy manuals and handbooks incorporated by reference therein.
717	These methodologies may include fee schedules, reimbursement
718	methods based on cost reporting, negotiated fees, competitive
719	bidding pursuant to s. 287.057, and other mechanisms the agency
720	considers efficient and effective for purchasing services or
721	goods on behalf of recipients. If a provider is reimbursed based
722	on cost reporting and submits a cost report late and that cost
723	report would have been used to set a lower reimbursement rate
724	for a rate semester, then the provider's rate for that semester
725	shall be retroactively calculated using the new cost report, and
726	full payment at the recalculated rate shall be effected
727	retroactively. Medicare-granted extensions for filing cost
728	reports, if applicable, shall also apply to Medicaid cost
729	reports. Payment for Medicaid compensable services made on
730	behalf of Medicaid eligible persons is subject to the
731	availability of moneys and any limitations or directions
732	provided for in the General Appropriations Act or chapter 216.
733	Further, nothing in this section shall be construed to prevent
734	or limit the agency from adjusting fees, reimbursement rates,
735	lengths of stay, number of visits, or number of services, or
736	making any other adjustments necessary to comply with the
737	availability of moneys and any limitations or directions
738	provided for in the General Appropriations Act, provided the
739	adjustment is consistent with legislative intent.
740	(24) If a provider fails to notify the agency within 5
741	business days after suspension or disenrollment from Medicare,
742	sanctions may be imposed pursuant to this chapter and the
743	provider may be required to return funds paid to the provider
744	during the period of time that the provider was suspended or
745	disenrolled as a Medicare provider.
746	Section 10. Section 409.912, Florida Statutes, is amended
747	to read:
748	409.912 Cost-effective purchasing of health care.-The
749	agency shall purchase goods and services for Medicaid recipients
750	in the most cost-effective manner consistent with the delivery
751	of quality medical care. To ensure that medical services are
752	effectively utilized, the agency may, in any case, require a
753	confirmation or second physician's opinion of the correct
754	diagnosis for purposes of authorizing future services under the
755	Medicaid program. This section does not restrict access to
756	emergency services or poststabilization care services as defined
757	in 42 C.F.R. part 438.114. Such confirmation or second opinion
758	shall be rendered in a manner approved by the agency. The agency
759	shall maximize the use of prepaid per capita and prepaid
760	aggregate fixed-sum basis services when appropriate and other
761	alternative service delivery and reimbursement methodologies,
762	including competitive bidding pursuant to s. 287.057, designed
763	to facilitate the cost-effective purchase of a case-managed
764	continuum of care. The agency shall also require providers to
765	minimize the exposure of recipients to the need for acute
766	inpatient, custodial, and other institutional care and the
767	inappropriate or unnecessary use of high-cost services. The
768	agency shall contract with a vendor to monitor and evaluate the
769	clinical practice patterns of providers in order to identify
770	trends that are outside the normal practice patterns of a
771	provider's professional peers or the national guidelines of a
772	provider's professional association. The vendor must be able to
773	provide information and counseling to a provider whose practice
774	patterns are outside the norms, in consultation with the agency,
775	to improve patient care and reduce inappropriate utilization.
776	The agency may mandate prior authorization, drug therapy
777	management, or disease management participation for certain
778	populations of Medicaid beneficiaries, certain drug classes, or
779	particular drugs to prevent fraud, abuse, overuse, and possible
780	dangerous drug interactions. The Pharmaceutical and Therapeutics
781	Committee shall make recommendations to the agency on drugs for
782	which prior authorization is required. The agency shall inform
783	the Pharmaceutical and Therapeutics Committee of its decisions
784	regarding drugs subject to prior authorization. The agency is
785	authorized to limit the entities it contracts with or enrolls as
786	Medicaid providers by developing a provider network through
787	provider credentialing. The agency may competitively bid single-
788	source-provider contracts if procurement of goods or services
789	results in demonstrated cost savings to the state without
790	limiting access to care. The agency may limit its network based
791	on the assessment of beneficiary access to care, provider
792	availability, provider quality standards, time and distance
793	standards for access to care, the cultural competence of the
794	provider network, demographic characteristics of Medicaid
795	beneficiaries, practice and provider-to-beneficiary standards,
796	appointment wait times, beneficiary use of services, provider
797	turnover, provider profiling, provider licensure history,
798	previous program integrity investigations and findings, peer
799	review, provider Medicaid policy and billing compliance records,
800	clinical and medical record audits, and other factors. Providers
801	shall not be entitled to enrollment in the Medicaid provider
802	network. The agency shall determine instances in which allowing
803	Medicaid beneficiaries to purchase durable medical equipment and
804	other goods is less expensive to the Medicaid program than long-
805	term rental of the equipment or goods. The agency may establish
806	rules to facilitate purchases in lieu of long-term rentals in
807	order to protect against fraud and abuse in the Medicaid program
808	as defined in s. 409.913. The agency may seek federal waivers
809	necessary to administer these policies.
810	(1) The agency shall work with the Department of Children
811	and Family Services to ensure access of children and families in
812	the child protection system to needed and appropriate mental
813	health and substance abuse services. This subsection expires
814	October 1, 2013.
815	(2) The agency may enter into agreements with appropriate
816	agents of other state agencies or of any agency of the Federal
817	Government and accept such duties in respect to social welfare
818	or public aid as may be necessary to implement the provisions of
819	Title XIX of the Social Security Act and ss. 409.901-409.920.
820	This subsection expires October 1, 2015.
821	(3) The agency may contract with health maintenance
822	organizations certified pursuant to part I of chapter 641 for
823	the provision of services to recipients. This subsection expires
824	October 1, 2013.
825	(4) The agency may contract with:
826	(a) An entity that provides no prepaid health care
827	services other than Medicaid services under contract with the
828	agency and which is owned and operated by a county, county
829	health department, or county-owned and operated hospital to
830	provide health care services on a prepaid or fixed-sum basis to
831	recipients, which entity may provide such prepaid services
832	either directly or through arrangements with other providers.
833	Such prepaid health care services entities must be licensed
834	under parts I and III of chapter 641. An entity recognized under
835	this paragraph which demonstrates to the satisfaction of the
836	Office of Insurance Regulation of the Financial Services
837	Commission that it is backed by the full faith and credit of the
838	county in which it is located may be exempted from s. 641.225.
839	This paragraph expires October 1, 2013.
840	(b) An entity that is providing comprehensive behavioral
841	health care services to certain Medicaid recipients through a
842	capitated, prepaid arrangement pursuant to the federal waiver
843	provided for by s. 409.905(5). Such entity must be licensed
844	under chapter 624, chapter 636, or chapter 641, or authorized
845	under paragraph (c) or paragraph (d), and must possess the
846	clinical systems and operational competence to manage risk and
847	provide comprehensive behavioral health care to Medicaid
848	recipients. As used in this paragraph, the term "comprehensive
849	behavioral health care services" means covered mental health and
850	substance abuse treatment services that are available to
851	Medicaid recipients. The secretary of the Department of Children
852	and Family Services shall approve provisions of procurements
853	related to children in the department's care or custody before
854	enrolling such children in a prepaid behavioral health plan. Any
855	contract awarded under this paragraph must be competitively
856	procured. In developing the behavioral health care prepaid plan
857	procurement document, the agency shall ensure that the
858	procurement document requires the contractor to develop and
859	implement a plan to ensure compliance with s. 394.4574 related
860	to services provided to residents of licensed assisted living
861	facilities that hold a limited mental health license. Except as
862	provided in subparagraph 5. 8., and except in counties where the
863	Medicaid managed care pilot program is authorized pursuant to s.
864	409.91211, the agency shall seek federal approval to contract
865	with a single entity meeting these requirements to provide
866	comprehensive behavioral health care services to all Medicaid
867	recipients not enrolled in a Medicaid managed care plan
868	authorized under s. 409.91211, a provider service network as
869	described in paragraph (d), or a Medicaid health maintenance
870	organization in an AHCA area. In an AHCA area where the Medicaid
871	managed care pilot program is authorized pursuant to s.
872	409.91211 in one or more counties, the agency may procure a
873	contract with a single entity to serve the remaining counties as
874	an AHCA area or the remaining counties may be included with an
875	adjacent AHCA area and are subject to this paragraph. Each
876	entity must offer a sufficient choice of providers in its
877	network to ensure recipient access to care and the opportunity
878	to select a provider with whom they are satisfied. The network
879	shall include all public mental health hospitals. To ensure
880	unimpaired access to behavioral health care services by Medicaid
881	recipients, all contracts issued pursuant to this paragraph must
882	require 80 percent of the capitation paid to the managed care
883	plan, including health maintenance organizations and capitated
884	provider service networks, to be expended for the provision of
885	behavioral health care services. If the managed care plan
886	expends less than 80 percent of the capitation paid for the
887	provision of behavioral health care services, the difference
888	shall be returned to the agency. The agency shall provide the
889	plan with a certification letter indicating the amount of
890	capitation paid during each calendar year for behavioral health
891	care services pursuant to this section. The agency may reimburse
892	for substance abuse treatment services on a fee-for-service
893	basis until the agency finds that adequate funds are available
894	for capitated, prepaid arrangements.
895	1. By January 1, 2001, The agency shall modify the
896	contracts with the entities providing comprehensive inpatient
897	and outpatient mental health care services to Medicaid
898	recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk
899	Counties, to include substance abuse treatment services.
900	2. By July 1, 2003, the agency and the Department of
901	Children and Family Services shall execute a written agreement
902	that requires collaboration and joint development of all policy,
903	budgets, procurement documents, contracts, and monitoring plans
904	that have an impact on the state and Medicaid community mental
905	health and targeted case management programs.
906	2.3. Except as provided in subparagraph 5. 8., by July 1,
907	2006, the agency and the Department of Children and Family
908	Services shall contract with managed care entities in each AHCA
909	area except area 6 or arrange to provide comprehensive inpatient
910	and outpatient mental health and substance abuse services
911	through capitated prepaid arrangements to all Medicaid
912	recipients who are eligible to participate in such plans under
913	federal law and regulation. In AHCA areas where eligible
914	individuals number less than 150,000, the agency shall contract
915	with a single managed care plan to provide comprehensive
916	behavioral health services to all recipients who are not
917	enrolled in a Medicaid health maintenance organization, a
918	provider service network as described in paragraph (d), or a
919	Medicaid capitated managed care plan authorized under s.
920	409.91211. The agency may contract with more than one
921	comprehensive behavioral health provider to provide care to
922	recipients who are not enrolled in a Medicaid capitated managed
923	care plan authorized under s. 409.91211, a provider service
924	network as described in paragraph (d), or a Medicaid health
925	maintenance organization in AHCA areas where the eligible
926	population exceeds 150,000. In an AHCA area where the Medicaid
927	managed care pilot program is authorized pursuant to s.
928	409.91211 in one or more counties, the agency may procure a
929	contract with a single entity to serve the remaining counties as
930	an AHCA area or the remaining counties may be included with an
931	adjacent AHCA area and shall be subject to this paragraph.
932	Contracts for comprehensive behavioral health providers awarded
933	pursuant to this section shall be competitively procured. Both
934	for-profit and not-for-profit corporations are eligible to
935	compete. Managed care plans contracting with the agency under
936	subsection (3) or paragraph (d), shall provide and receive
937	payment for the same comprehensive behavioral health benefits as
938	provided in AHCA rules, including handbooks incorporated by
939	reference. In AHCA area 11, the agency shall contract with at
940	least two comprehensive behavioral health care providers to
941	provide behavioral health care to recipients in that area who
942	are enrolled in, or assigned to, the MediPass program. One of
943	the behavioral health care contracts must be with the existing
944	provider service network pilot project, as described in
945	paragraph (d), for the purpose of demonstrating the cost-
946	effectiveness of the provision of quality mental health services
947	through a public hospital-operated managed care model. Payment
948	shall be at an agreed-upon capitated rate to ensure cost
949	savings. Of the recipients in area 11 who are assigned to
950	MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
951	MediPass-enrolled recipients shall be assigned to the existing
952	provider service network in area 11 for their behavioral care.
953	4. By October 1, 2003, the agency and the department shall
954	submit a plan to the Governor, the President of the Senate, and
955	the Speaker of the House of Representatives which provides for
956	the full implementation of capitated prepaid behavioral health
957	care in all areas of the state.
958	a. Implementation shall begin in 2003 in those AHCA areas
959	of the state where the agency is able to establish sufficient
960	capitation rates.
961	b. If the agency determines that the proposed capitation
962	rate in any area is insufficient to provide appropriate
963	services, the agency may adjust the capitation rate to ensure
964	that care will be available. The agency and the department may
965	use existing general revenue to address any additional required
966	match but may not over-obligate existing funds on an annualized
967	basis.
968	c. Subject to any limitations provided in the General
969	Appropriations Act, the agency, in compliance with appropriate
970	federal authorization, shall develop policies and procedures
971	that allow for certification of local and state funds.
972	3.5. Children residing in a statewide inpatient
973	psychiatric program, or in a Department of Juvenile Justice or a
974	Department of Children and Family Services residential program
975	approved as a Medicaid behavioral health overlay services
976	provider may not be included in a behavioral health care prepaid
977	health plan or any other Medicaid managed care plan pursuant to
978	this paragraph.
979	6. In converting to a prepaid system of delivery, the
980	agency shall in its procurement document require an entity
981	providing only comprehensive behavioral health care services to
982	prevent the displacement of indigent care patients by enrollees
983	in the Medicaid prepaid health plan providing behavioral health
984	care services from facilities receiving state funding to provide
985	indigent behavioral health care, to facilities licensed under
986	chapter 395 which do not receive state funding for indigent
987	behavioral health care, or reimburse the unsubsidized facility
988	for the cost of behavioral health care provided to the displaced
989	indigent care patient.
990	4.7. Traditional community mental health providers under
991	contract with the Department of Children and Family Services
992	pursuant to part IV of chapter 394, child welfare providers
993	under contract with the Department of Children and Family
994	Services in areas 1 and 6, and inpatient mental health providers
995	licensed pursuant to chapter 395 must be offered an opportunity
996	to accept or decline a contract to participate in any provider
997	network for prepaid behavioral health services.
998	5.8. All Medicaid-eligible children, except children in
999	area 1 and children in Highlands County, Hardee County, Polk
1000	County, or Manatee County of area 6, that are open for child
1001	welfare services in the HomeSafeNet system, shall receive their
1002	behavioral health care services through a specialty prepaid plan
1003	operated by community-based lead agencies through a single
1004	agency or formal agreements among several agencies. The
1005	specialty prepaid plan must result in savings to the state
1006	comparable to savings achieved in other Medicaid managed care
1007	and prepaid programs. Such plan must provide mechanisms to
1008	maximize state and local revenues. The specialty prepaid plan
1009	shall be developed by the agency and the Department of Children
1010	and Family Services. The agency may seek federal waivers to
1011	implement this initiative. Medicaid-eligible children whose
1012	cases are open for child welfare services in the HomeSafeNet
1013	system and who reside in AHCA area 10 shall be enrolled in
1014	capitated managed care plans that, in coordination with
1015	available community-based care providers specified in s.
1016	409.1671, provide sufficient medical, developmental, behavioral
1017	and emotional services to meet the needs of these children. are
1018	exempt from the specialty prepaid plan upon the development of a
1019	service delivery mechanism for children who reside in area 10 as
1020	specified in s. 409.91211(3)(dd).
1021
1022	This paragraph expires October 1, 2013.
1023	(c) A federally qualified health center or an entity owned
1024	by one or more federally qualified health centers or an entity
1025	owned by other migrant and community health centers receiving
1026	non-Medicaid financial support from the Federal Government to
1027	provide health care services on a prepaid or fixed-sum basis to
1028	recipients. A federally qualified health center or an entity
1029	that is owned by one or more federally qualified health centers
1030	and is reimbursed by the agency on a prepaid basis is exempt
1031	from parts I and III of chapter 641, but must comply with the
1032	solvency requirements in s. 641.2261(2) and meet the appropriate
1033	requirements governing financial reserve, quality assurance, and
1034	patients' rights established by the agency. This paragraph
1035	expires October 1, 2013.
1036	(d)1. A provider service network may be reimbursed on a
1037	fee-for-service or prepaid basis. Prepaid provider service
1038	networks receive per-member per-month payments. Provider service
1039	networks that do not choose to be prepaid plans shall receive
1040	fee-for-service rates with a shared savings settlement. The fee-
1041	for-service option shall be available to a provider service
1042	network only for the first 5 years of the plan's operation in a
1043	given region or until the contract year beginning October 1,
1044	2015, whichever is later. The agency shall annually conduct cost
1045	reconciliations to determine the amount of cost savings achieved
1046	by fee-for-service provider service networks for the dates of
1047	service in the period being reconciled. Only payments for
1048	covered services for dates of service within the reconciliation
1049	period and paid within 6 months after the last date of service
1050	in the reconciliation period shall be included. The agency shall
1051	perform the necessary adjustments for the inclusion of claims
1052	incurred but not reported within the reconciliation for claims
1053	that could be received and paid by the agency after the 6-month
1054	claims processing time lag. The agency shall provide the results
1055	of the reconciliations to the fee-for-service provider service
1056	networks within 45 days after the end of the reconciliation
1057	period. The fee-for-service provider service networks shall
1058	review and provide written comments or a letter of concurrence
1059	to the agency within 45 days after receipt of the reconciliation
1060	results. This reconciliation shall be considered final.
1061	2. A provider service network which is reimbursed by the
1062	agency on a prepaid basis shall be exempt from parts I and III
1063	of chapter 641, but must comply with the solvency requirements
1064	in s. 641.2261(2) and meet appropriate financial reserve,
1065	quality assurance, and patient rights requirements as
1066	established by the agency.
1067	3. Medicaid recipients assigned to a provider service
1068	network shall be chosen equally from those who would otherwise
1069	have been assigned to prepaid plans and MediPass. The agency is
1070	authorized to seek federal Medicaid waivers as necessary to
1071	implement the provisions of this section. This subparagraph
1072	expires October 1, 2013. Any contract previously awarded to a
1073	provider service network operated by a hospital pursuant to this
1074	subsection shall remain in effect for a period of 3 years
1075	following the current contract expiration date, regardless of
1076	any contractual provisions to the contrary.
1077	4. A provider service network is a network established or
1078	organized and operated by a health care provider, or group of
1079	affiliated health care providers, including minority physician
1080	networks and emergency room diversion programs that meet the
1081	requirements of s. 409.91211, which provides a substantial
1082	proportion of the health care items and services under a
1083	contract directly through the provider or affiliated group of
1084	providers and may make arrangements with physicians or other
1085	health care professionals, health care institutions, or any
1086	combination of such individuals or institutions to assume all or
1087	part of the financial risk on a prospective basis for the
1088	provision of basic health services by the physicians, by other
1089	health professionals, or through the institutions. The health
1090	care providers must have a controlling interest in the governing
1091	body of the provider service network organization.
1092	(e) An entity that provides only comprehensive behavioral
1093	health care services to certain Medicaid recipients through an
1094	administrative services organization agreement. Such an entity
1095	must possess the clinical systems and operational competence to
1096	provide comprehensive health care to Medicaid recipients. As
1097	used in this paragraph, the term "comprehensive behavioral
1098	health care services" means covered mental health and substance
1099	abuse treatment services that are available to Medicaid
1100	recipients. Any contract awarded under this paragraph must be
1101	competitively procured. The agency must ensure that Medicaid
1102	recipients have available the choice of at least two managed
1103	care plans for their behavioral health care services. This
1104	paragraph expires October 1, 2013.
1105	(f) An entity that provides in-home physician services to
1106	test the cost-effectiveness of enhanced home-based medical care
1107	to Medicaid recipients with degenerative neurological diseases
1108	and other diseases or disabling conditions associated with high
1109	costs to Medicaid. The program shall be designed to serve very
1110	disabled persons and to reduce Medicaid reimbursed costs for
1111	inpatient, outpatient, and emergency department services. The
1112	agency shall contract with vendors on a risk-sharing basis.
1113	(g) Children's provider networks that provide care
1114	coordination and care management for Medicaid-eligible pediatric
1115	patients, primary care, authorization of specialty care, and
1116	other urgent and emergency care through organized providers
1117	designed to service Medicaid eligibles under age 18 and
1118	pediatric emergency departments' diversion programs. The
1119	networks shall provide after-hour operations, including evening
1120	and weekend hours, to promote, when appropriate, the use of the
1121	children's networks rather than hospital emergency departments.
1122	(f)(h) An entity authorized in s. 430.205 to contract with
1123	the agency and the Department of Elderly Affairs to provide
1124	health care and social services on a prepaid or fixed-sum basis
1125	to elderly recipients. Such prepaid health care services
1126	entities are exempt from the provisions of part I of chapter 641
1127	for the first 3 years of operation. An entity recognized under
1128	this paragraph that demonstrates to the satisfaction of the
1129	Office of Insurance Regulation that it is backed by the full
1130	faith and credit of one or more counties in which it operates
1131	may be exempted from s. 641.225. This paragraph expires October
1132	1, 2012.
1133	(g)(i) A Children's Medical Services Network, as defined
1134	in s. 391.021. This paragraph expires October 1, 2013.
1135	(5) The Agency for Health Care Administration, in
1136	partnership with the Department of Elderly Affairs, shall create
1137	an integrated, fixed-payment delivery program for Medicaid
1138	recipients who are 60 years of age or older or dually eligible
1139	for Medicare and Medicaid. The Agency for Health Care
1140	Administration shall implement the integrated program initially
1141	on a pilot basis in two areas of the state. The pilot areas
1142	shall be Area 7 and Area 11 of the Agency for Health Care
1143	Administration. Enrollment in the pilot areas shall be on a
1144	voluntary basis and in accordance with approved federal waivers
1145	and this section. The agency and its program contractors and
1146	providers shall not enroll any individual in the integrated
1147	program because the individual or the person legally responsible
1148	for the individual fails to choose to enroll in the integrated
1149	program. Enrollment in the integrated program shall be
1150	exclusively by affirmative choice of the eligible individual or
1151	by the person legally responsible for the individual. The
1152	integrated program must transfer all Medicaid services for
1153	eligible elderly individuals who choose to participate into an
1154	integrated-care management model designed to serve Medicaid
1155	recipients in the community. The integrated program must combine
1156	all funding for Medicaid services provided to individuals who
1157	are 60 years of age or older or dually eligible for Medicare and
1158	Medicaid into the integrated program, including funds for
1159	Medicaid home and community-based waiver services; all Medicaid
1160	services authorized in ss. 409.905 and 409.906, excluding funds
1161	for Medicaid nursing home services unless the agency is able to
1162	demonstrate how the integration of the funds will improve
1163	coordinated care for these services in a less costly manner; and
1164	Medicare coinsurance and deductibles for persons dually eligible
1165	for Medicaid and Medicare as prescribed in s. 409.908(13).
1166	(a) Individuals who are 60 years of age or older or dually
1167	eligible for Medicare and Medicaid and enrolled in the
1168	developmental disabilities waiver program, the family and
1169	supported-living waiver program, the project AIDS care waiver
1170	program, the traumatic brain injury and spinal cord injury
1171	waiver program, the consumer-directed care waiver program, and
1172	the program of all-inclusive care for the elderly program, and
1173	residents of institutional care facilities for the
1174	developmentally disabled, must be excluded from the integrated
1175	program.
1176	(b) Managed care entities who meet or exceed the agency's
1177	minimum standards are eligible to operate the integrated
1178	program. Entities eligible to participate include managed care
1179	organizations licensed under chapter 641, including entities
1180	eligible to participate in the nursing home diversion program,
1181	other qualified providers as defined in s. 430.703(7), community
1182	care for the elderly lead agencies, and other state-certified
1183	community service networks that meet comparable standards as
1184	defined by the agency, in consultation with the Department of
1185	Elderly Affairs and the Office of Insurance Regulation, to be
1186	financially solvent and able to take on financial risk for
1187	managed care. Community service networks that are certified
1188	pursuant to the comparable standards defined by the agency are
1189	not required to be licensed under chapter 641. Managed care
1190	entities who operate the integrated program shall be subject to
1191	s. 408.7056. Eligible entities shall choose to serve enrollees
1192	who are dually eligible for Medicare and Medicaid, enrollees who
1193	are 60 years of age or older, or both.
1194	(c) The agency must ensure that the capitation-rate-
1195	setting methodology for the integrated program is actuarially
1196	sound and reflects the intent to provide quality care in the
1197	least restrictive setting. The agency must also require
1198	integrated-program providers to develop a credentialing system
1199	for service providers and to contract with all Gold Seal nursing
1200	homes, where feasible, and exclude, where feasible, chronically
1201	poor-performing facilities and providers as defined by the
1202	agency. The integrated program must develop and maintain an
1203	informal provider grievance system that addresses provider
1204	payment and contract problems. The agency shall also establish a
1205	formal grievance system to address those issues that were not
1206	resolved through the informal grievance system. The integrated
1207	program must provide that if the recipient resides in a
1208	noncontracted residential facility licensed under chapter 400 or
1209	chapter 429 at the time of enrollment in the integrated program,
1210	the recipient must be permitted to continue to reside in the
1211	noncontracted facility as long as the recipient desires. The
1212	integrated program must also provide that, in the absence of a
1213	contract between the integrated-program provider and the
1214	residential facility licensed under chapter 400 or chapter 429,
1215	current Medicaid rates must prevail. The integrated-program
1216	provider must ensure that electronic nursing home claims that
1217	contain sufficient information for processing are paid within 10
1218	business days after receipt. Alternately, the integrated-program
1219	provider may establish a capitated payment mechanism to
1220	prospectively pay nursing homes at the beginning of each month.
1221	The agency and the Department of Elderly Affairs must jointly
1222	develop procedures to manage the services provided through the
1223	integrated program in order to ensure quality and recipient
1224	choice.
1225	(d) The Office of Program Policy Analysis and Government
1226	Accountability, in consultation with the Auditor General, shall
1227	comprehensively evaluate the pilot project for the integrated,
1228	fixed-payment delivery program for Medicaid recipients created
1229	under this subsection. The evaluation shall begin as soon as
1230	Medicaid recipients are enrolled in the managed care pilot
1231	program plans and shall continue for 24 months thereafter. The
1232	evaluation must include assessments of each managed care plan in
1233	the integrated program with regard to cost savings; consumer
1234	education, choice, and access to services; coordination of care;
1235	and quality of care. The evaluation must describe administrative
1236	or legal barriers to the implementation and operation of the
1237	pilot program and include recommendations regarding statewide
1238	expansion of the pilot program. The office shall submit its
1239	evaluation report to the Governor, the President of the Senate,
1240	and the Speaker of the House of Representatives no later than
1241	December 31, 2009.
1242	(e) The agency may seek federal waivers or Medicaid state
1243	plan amendments and adopt rules as necessary to administer the
1244	integrated program. The agency may implement the approved
1245	federal waivers and other provisions as specified in this
1246	subsection.
1247	(f) No later than December 31, 2007, the agency shall
1248	provide a report to the Governor, the President of the Senate,
1249	and the Speaker of the House of Representatives containing an
1250	analysis of the merits and challenges of seeking a waiver to
1251	implement a voluntary program that integrates payments and
1252	services for dually enrolled Medicare and Medicaid recipients
1253	who are 65 years of age or older.
1254	(g) The implementation of the integrated, fixed-payment
1255	delivery program created under this subsection is subject to an
1256	appropriation in the General Appropriations Act.
1257	(5)(6) The agency may contract with any public or private
1258	entity otherwise authorized by this section on a prepaid or
1259	fixed-sum basis for the provision of health care services to
1260	recipients. An entity may provide prepaid services to
1261	recipients, either directly or through arrangements with other
1262	entities, if each entity involved in providing services:
1263	(a) Is organized primarily for the purpose of providing
1264	health care or other services of the type regularly offered to
1265	Medicaid recipients;
1266	(b) Ensures that services meet the standards set by the
1267	agency for quality, appropriateness, and timeliness;
1268	(c) Makes provisions satisfactory to the agency for
1269	insolvency protection and ensures that neither enrolled Medicaid
1270	recipients nor the agency will be liable for the debts of the
1271	entity;
1272	(d) Submits to the agency, if a private entity, a
1273	financial plan that the agency finds to be fiscally sound and
1274	that provides for working capital in the form of cash or
1275	equivalent liquid assets excluding revenues from Medicaid
1276	premium payments equal to at least the first 3 months of
1277	operating expenses or $200,000, whichever is greater;
1278	(e) Furnishes evidence satisfactory to the agency of
1279	adequate liability insurance coverage or an adequate plan of
1280	self-insurance to respond to claims for injuries arising out of
1281	the furnishing of health care;
1282	(f) Provides, through contract or otherwise, for periodic
1283	review of its medical facilities and services, as required by
1284	the agency; and
1285	(g) Provides organizational, operational, financial, and
1286	other information required by the agency.
1287
1288	This subsection expires October 1, 2013.
1289	(6)(7) The agency may contract on a prepaid or fixed-sum
1290	basis with any health insurer that:
1291	(a) Pays for health care services provided to enrolled
1292	Medicaid recipients in exchange for a premium payment paid by
1293	the agency;
1294	(b) Assumes the underwriting risk; and
1295	(c) Is organized and licensed under applicable provisions
1296	of the Florida Insurance Code and is currently in good standing
1297	with the Office of Insurance Regulation.
1298
1299	This subsection expires October 1, 2013.
1300	(7)(8)(a) The agency may contract on a prepaid or fixed-
1301	sum basis with an exclusive provider organization to provide
1302	health care services to Medicaid recipients provided that the
1303	exclusive provider organization meets applicable managed care
1304	plan requirements in this section, ss. 409.9122, 409.9123,
1305	409.9128, and 627.6472, and other applicable provisions of law.
1306	This subsection expires October 1, 2013.
1307	(b) For a period of no longer than 24 months after the
1308	effective date of this paragraph, when a member of an exclusive
1309	provider organization that is contracted by the agency to
1310	provide health care services to Medicaid recipients in rural
1311	areas without a health maintenance organization obtains services
1312	from a provider that participates in the Medicaid program in
1313	this state, the provider shall be paid in accordance with the
1314	appropriate fee schedule for services provided to eligible
1315	Medicaid recipients. The agency may seek waiver authority to
1316	implement this paragraph.
1317	(8)(9) The Agency for Health Care Administration may
1318	provide cost-effective purchasing of chiropractic services on a
1319	fee-for-service basis to Medicaid recipients through
1320	arrangements with a statewide chiropractic preferred provider
1321	organization incorporated in this state as a not-for-profit
1322	corporation. The agency shall ensure that the benefit limits and
1323	prior authorization requirements in the current Medicaid program
1324	shall apply to the services provided by the chiropractic
1325	preferred provider organization. This subsection expires October
1326	1, 2013.
1327	(9)(10) The agency shall not contract on a prepaid or
1328	fixed-sum basis for Medicaid services with an entity which knows
1329	or reasonably should know that any officer, director, agent,
1330	managing employee, or owner of stock or beneficial interest in
1331	excess of 5 percent common or preferred stock, or the entity
1332	itself, has been found guilty of, regardless of adjudication, or
1333	entered a plea of nolo contendere, or guilty, to:
1334	(a) Fraud;
1335	(b) Violation of federal or state antitrust statutes,
1336	including those proscribing price fixing between competitors and
1337	the allocation of customers among competitors;
1338	(c) Commission of a felony involving embezzlement, theft,
1339	forgery, income tax evasion, bribery, falsification or
1340	destruction of records, making false statements, receiving
1341	stolen property, making false claims, or obstruction of justice;
1342	or
1343	(d) Any crime in any jurisdiction which directly relates
1344	to the provision of health services on a prepaid or fixed-sum
1345	basis.
1346
1347	This subsection expires October 1, 2013.
1348	(10)(11) The agency, after notifying the Legislature, may
1349	apply for waivers of applicable federal laws and regulations as
1350	necessary to implement more appropriate systems of health care
1351	for Medicaid recipients and reduce the cost of the Medicaid
1352	program to the state and federal governments and shall implement
1353	such programs, after legislative approval, within a reasonable
1354	period of time after federal approval. These programs must be
1355	designed primarily to reduce the need for inpatient care,
1356	custodial care and other long-term or institutional care, and
1357	other high-cost services. Prior to seeking legislative approval
1358	of such a waiver as authorized by this subsection, the agency
1359	shall provide notice and an opportunity for public comment.
1360	Notice shall be provided to all persons who have made requests
1361	of the agency for advance notice and shall be published in the
1362	Florida Administrative Weekly not less than 28 days prior to the
1363	intended action. This subsection expires October 1, 2015.
1364	(11)(12) The agency shall establish a postpayment
1365	utilization control program designed to identify recipients who
1366	may inappropriately overuse or underuse Medicaid services and
1367	shall provide methods to correct such misuse. This subsection
1368	expires October 1, 2013.
1369	(12)(13) The agency shall develop and provide coordinated
1370	systems of care for Medicaid recipients and may contract with
1371	public or private entities to develop and administer such
1372	systems of care among public and private health care providers
1373	in a given geographic area. This subsection expires October 1,
1374	2013.
1375	(13)(14)(a) The agency shall operate or contract for the
1376	operation of utilization management and incentive systems
1377	designed to encourage cost-effective use of services and to
1378	eliminate services that are medically unnecessary. The agency
1379	shall track Medicaid provider prescription and billing patterns
1380	and evaluate them against Medicaid medical necessity criteria
1381	and coverage and limitation guidelines adopted by rule. Medical
1382	necessity determination requires that service be consistent with
1383	symptoms or confirmed diagnosis of illness or injury under
1384	treatment and not in excess of the patient's needs. The agency
1385	shall conduct reviews of provider exceptions to peer group norms
1386	and shall, using statistical methodologies, provider profiling,
1387	and analysis of billing patterns, detect and investigate
1388	abnormal or unusual increases in billing or payment of claims
1389	for Medicaid services and medically unnecessary provision of
1390	services. Providers that demonstrate a pattern of submitting
1391	claims for medically unnecessary services shall be referred to
1392	the Medicaid program integrity unit for investigation. In its
1393	annual report, required in s. 409.913, the agency shall report
1394	on its efforts to control overutilization as described in this
1395	subsection paragraph. This subsection expires October 1, 2013.
1396	(b) The agency shall develop a procedure for determining
1397	whether health care providers and service vendors can provide
1398	the Medicaid program using a business case that demonstrates
1399	whether a particular good or service can offset the cost of
1400	providing the good or service in an alternative setting or
1401	through other means and therefore should receive a higher
1402	reimbursement. The business case must include, but need not be
1403	limited to:
1404	1. A detailed description of the good or service to be
1405	provided, a description and analysis of the agency's current
1406	performance of the service, and a rationale documenting how
1407	providing the service in an alternative setting would be in the
1408	best interest of the state, the agency, and its clients.
1409	2. A cost-benefit analysis documenting the estimated
1410	specific direct and indirect costs, savings, performance
1411	improvements, risks, and qualitative and quantitative benefits
1412	involved in or resulting from providing the service. The cost-
1413	benefit analysis must include a detailed plan and timeline
1414	identifying all actions that must be implemented to realize
1415	expected benefits. The Secretary of Health Care Administration
1416	shall verify that all costs, savings, and benefits are valid and
1417	achievable.
1418	(c) If the agency determines that the increased
1419	reimbursement is cost-effective, the agency shall recommend a
1420	change in the reimbursement schedule for that particular good or
1421	service. If, within 12 months after implementing any rate change
1422	under this procedure, the agency determines that costs were not
1423	offset by the increased reimbursement schedule, the agency may
1424	revert to the former reimbursement schedule for the particular
1425	good or service.
1426	(14)(15)(a) The agency shall operate the Comprehensive
1427	Assessment and Review for Long-Term Care Services (CARES)
1428	nursing facility preadmission screening program to ensure that
1429	Medicaid payment for nursing facility care is made only for
1430	individuals whose conditions require such care and to ensure
1431	that long-term care services are provided in the setting most
1432	appropriate to the needs of the person and in the most
1433	economical manner possible. The CARES program shall also ensure
1434	that individuals participating in Medicaid home and community-
1435	based waiver programs meet criteria for those programs,
1436	consistent with approved federal waivers.
1437	(b) The agency shall operate the CARES program through an
1438	interagency agreement with the Department of Elderly Affairs.
1439	The agency, in consultation with the Department of Elderly
1440	Affairs, may contract for any function or activity of the CARES
1441	program, including any function or activity required by 42
1442	C.F.R. part 483.20, relating to preadmission screening and
1443	resident review.
1444	(c) Prior to making payment for nursing facility services
1445	for a Medicaid recipient, the agency must verify that the
1446	nursing facility preadmission screening program has determined
1447	that the individual requires nursing facility care and that the
1448	individual cannot be safely served in community-based programs.
1449	The nursing facility preadmission screening program shall refer
1450	a Medicaid recipient to a community-based program if the
1451	individual could be safely served at a lower cost and the
1452	recipient chooses to participate in such program. For
1453	individuals whose nursing home stay is initially funded by
1454	Medicare and Medicare coverage is being terminated for lack of
1455	progress towards rehabilitation, CARES staff shall consult with
1456	the person making the determination of progress toward
1457	rehabilitation to ensure that the recipient is not being
1458	inappropriately disqualified from Medicare coverage. If, in
1459	their professional judgment, CARES staff believes that a
1460	Medicare beneficiary is still making progress toward
1461	rehabilitation, they may assist the Medicare beneficiary with an
1462	appeal of the disqualification from Medicare coverage. The use
1463	of CARES teams to review Medicare denials for coverage under
1464	this section is authorized only if it is determined that such
1465	reviews qualify for federal matching funds through Medicaid. The
1466	agency shall seek or amend federal waivers as necessary to
1467	implement this section.
1468	(d) For the purpose of initiating immediate prescreening
1469	and diversion assistance for individuals residing in nursing
1470	homes and in order to make families aware of alternative long-
1471	term care resources so that they may choose a more cost-
1472	effective setting for long-term placement, CARES staff shall
1473	conduct an assessment and review of a sample of individuals
1474	whose nursing home stay is expected to exceed 20 days,
1475	regardless of the initial funding source for the nursing home
1476	placement. CARES staff shall provide counseling and referral
1477	services to these individuals regarding choosing appropriate
1478	long-term care alternatives. This paragraph does not apply to
1479	continuing care facilities licensed under chapter 651 or to
1480	retirement communities that provide a combination of nursing
1481	home, independent living, and other long-term care services.
1482	(e) By January 15 of each year, the agency shall submit a
1483	report to the Legislature describing the operations of the CARES
1484	program. The report must describe:
1485	1. Rate of diversion to community alternative programs;
1486	2. CARES program staffing needs to achieve additional
1487	diversions;
1488	3. Reasons the program is unable to place individuals in
1489	less restrictive settings when such individuals desired such
1490	services and could have been served in such settings;
1491	4. Barriers to appropriate placement, including barriers
1492	due to policies or operations of other agencies or state-funded
1493	programs; and
1494	5. Statutory changes necessary to ensure that individuals
1495	in need of long-term care services receive care in the least
1496	restrictive environment.
1497	(f) The Department of Elderly Affairs shall track
1498	individuals over time who are assessed under the CARES program
1499	and who are diverted from nursing home placement. By January 15
1500	of each year, the department shall submit to the Legislature a
1501	longitudinal study of the individuals who are diverted from
1502	nursing home placement. The study must include:
1503	1. The demographic characteristics of the individuals
1504	assessed and diverted from nursing home placement, including,
1505	but not limited to, age, race, gender, frailty, caregiver
1506	status, living arrangements, and geographic location;
1507	2. A summary of community services provided to individuals
1508	for 1 year after assessment and diversion;
1509	3. A summary of inpatient hospital admissions for
1510	individuals who have been diverted; and
1511	4. A summary of the length of time between diversion and
1512	subsequent entry into a nursing home or death.
1513	(g) By July 1, 2005, the department and the Agency for
1514	Health Care Administration shall report to the President of the
1515	Senate and the Speaker of the House of Representatives regarding
1516	the impact to the state of modifying level-of-care criteria to
1517	eliminate the Intermediate II level of care.
1518
1519	This subsection expires October 1, 2012.
1520	(15)(16)(a) The agency shall identify health care
1521	utilization and price patterns within the Medicaid program which
1522	are not cost-effective or medically appropriate and assess the
1523	effectiveness of new or alternate methods of providing and
1524	monitoring service, and may implement such methods as it
1525	considers appropriate. Such methods may include disease
1526	management initiatives, an integrated and systematic approach
1527	for managing the health care needs of recipients who are at risk
1528	of or diagnosed with a specific disease by using best practices,
1529	prevention strategies, clinical-practice improvement, clinical
1530	interventions and protocols, outcomes research, information
1531	technology, and other tools and resources to reduce overall
1532	costs and improve measurable outcomes.
1533	(b) The responsibility of the agency under this subsection
1534	shall include the development of capabilities to identify actual
1535	and optimal practice patterns; patient and provider educational
1536	initiatives; methods for determining patient compliance with
1537	prescribed treatments; fraud, waste, and abuse prevention and
1538	detection programs; and beneficiary case management programs.
1539	1. The practice pattern identification program shall
1540	evaluate practitioner prescribing patterns based on national and
1541	regional practice guidelines, comparing practitioners to their
1542	peer groups. The agency and its Drug Utilization Review Board
1543	shall consult with the Department of Health and a panel of
1544	practicing health care professionals consisting of the
1545	following: the Speaker of the House of Representatives and the
1546	President of the Senate shall each appoint three physicians
1547	licensed under chapter 458 or chapter 459; and the Governor
1548	shall appoint two pharmacists licensed under chapter 465 and one
1549	dentist licensed under chapter 466 who is an oral surgeon. Terms
1550	of the panel members shall expire at the discretion of the
1551	appointing official. The advisory panel shall be responsible for
1552	evaluating treatment guidelines and recommending ways to
1553	incorporate their use in the practice pattern identification
1554	program. Practitioners who are prescribing inappropriately or
1555	inefficiently, as determined by the agency, may have their
1556	prescribing of certain drugs subject to prior authorization or
1557	may be terminated from all participation in the Medicaid
1558	program.
1559	2. The agency shall also develop educational interventions
1560	designed to promote the proper use of medications by providers
1561	and beneficiaries.
1562	3. The agency shall implement a pharmacy fraud, waste, and
1563	abuse initiative that may include a surety bond or letter of
1564	credit requirement for participating pharmacies, enhanced
1565	provider auditing practices, the use of additional fraud and
1566	abuse software, recipient management programs for beneficiaries
1567	inappropriately using their benefits, and other steps that will
1568	eliminate provider and recipient fraud, waste, and abuse. The
1569	initiative shall address enforcement efforts to reduce the
1570	number and use of counterfeit prescriptions.
1571	4. By September 30, 2002, the agency shall contract with
1572	an entity in the state to implement a wireless handheld clinical
1573	pharmacology drug information database for practitioners. The
1574	initiative shall be designed to enhance the agency's efforts to
1575	reduce fraud, abuse, and errors in the prescription drug benefit
1576	program and to otherwise further the intent of this paragraph.
1577	5. By April 1, 2006, the agency shall contract with an
1578	entity to design a database of clinical utilization information
1579	or electronic medical records for Medicaid providers. This
1580	system must be web-based and allow providers to review on a
1581	real-time basis the utilization of Medicaid services, including,
1582	but not limited to, physician office visits, inpatient and
1583	outpatient hospitalizations, laboratory and pathology services,
1584	radiological and other imaging services, dental care, and
1585	patterns of dispensing prescription drugs in order to coordinate
1586	care and identify potential fraud and abuse.
1587	6. The agency may apply for any federal waivers needed to
1588	administer this paragraph.
1589
1590	This subsection expires October 1, 2013.
1591	(16)(17) An entity contracting on a prepaid or fixed-sum
1592	basis shall meet the surplus requirements of s. 641.225. If an
1593	entity's surplus falls below an amount equal to the surplus
1594	requirements of s. 641.225, the agency shall prohibit the entity
1595	from engaging in marketing and preenrollment activities, shall
1596	cease to process new enrollments, and may not renew the entity's
1597	contract until the required balance is achieved. The
1598	requirements of this subsection do not apply:
1599	(a) Where a public entity agrees to fund any deficit
1600	incurred by the contracting entity; or
1601	(b) Where the entity's performance and obligations are
1602	guaranteed in writing by a guaranteeing organization which:
1603	1. Has been in operation for at least 5 years and has
1604	assets in excess of $50 million; or
1605	2. Submits a written guarantee acceptable to the agency
1606	which is irrevocable during the term of the contracting entity's
1607	contract with the agency and, upon termination of the contract,
1608	until the agency receives proof of satisfaction of all
1609	outstanding obligations incurred under the contract.
1610
1611	This subsection expires October 1, 2013.
1612	(17)(18)(a) The agency may require an entity contracting
1613	on a prepaid or fixed-sum basis to establish a restricted
1614	insolvency protection account with a federally guaranteed
1615	financial institution licensed to do business in this state. The
1616	entity shall deposit into that account 5 percent of the
1617	capitation payments made by the agency each month until a
1618	maximum total of 2 percent of the total current contract amount
1619	is reached. The restricted insolvency protection account may be
1620	drawn upon with the authorized signatures of two persons
1621	designated by the entity and two representatives of the agency.
1622	If the agency finds that the entity is insolvent, the agency may
1623	draw upon the account solely with the two authorized signatures
1624	of representatives of the agency, and the funds may be disbursed
1625	to meet financial obligations incurred by the entity under the
1626	prepaid contract. If the contract is terminated, expired, or not
1627	continued, the account balance must be released by the agency to
1628	the entity upon receipt of proof of satisfaction of all
1629	outstanding obligations incurred under this contract.
1630	(b) The agency may waive the insolvency protection account
1631	requirement in writing when evidence is on file with the agency
1632	of adequate insolvency insurance and reinsurance that will
1633	protect enrollees if the entity becomes unable to meet its
1634	obligations.
1635
1636	This subsection expires October 1, 2013.
1637	(18)(19) An entity that contracts with the agency on a
1638	prepaid or fixed-sum basis for the provision of Medicaid
1639	services shall reimburse any hospital or physician that is
1640	outside the entity's authorized geographic service area as
1641	specified in its contract with the agency, and that provides
1642	services authorized by the entity to its members, at a rate
1643	negotiated with the hospital or physician for the provision of
1644	services or according to the lesser of the following:
1645	(a) The usual and customary charges made to the general
1646	public by the hospital or physician; or
1647	(b) The Florida Medicaid reimbursement rate established
1648	for the hospital or physician.
1649
1650	This subsection expires October 1, 2013.
1651	(19)(20) When a merger or acquisition of a Medicaid
1652	prepaid contractor has been approved by the Office of Insurance
1653	Regulation pursuant to s. 628.4615, the agency shall approve the
1654	assignment or transfer of the appropriate Medicaid prepaid
1655	contract upon request of the surviving entity of the merger or
1656	acquisition if the contractor and the other entity have been in
1657	good standing with the agency for the most recent 12-month
1658	period, unless the agency determines that the assignment or
1659	transfer would be detrimental to the Medicaid recipients or the
1660	Medicaid program. To be in good standing, an entity must not
1661	have failed accreditation or committed any material violation of
1662	the requirements of s. 641.52 and must meet the Medicaid
1663	contract requirements. For purposes of this section, a merger or
1664	acquisition means a change in controlling interest of an entity,
1665	including an asset or stock purchase. This subsection expires
1666	October 1, 2013.
1667	(20)(21) Any entity contracting with the agency pursuant
1668	to this section to provide health care services to Medicaid
1669	recipients is prohibited from engaging in any of the following
1670	practices or activities:
1671	(a) Practices that are discriminatory, including, but not
1672	limited to, attempts to discourage participation on the basis of
1673	actual or perceived health status.
1674	(b) Activities that could mislead or confuse recipients,
1675	or misrepresent the organization, its marketing representatives,
1676	or the agency. Violations of this paragraph include, but are not
1677	limited to:
1678	1. False or misleading claims that marketing
1679	representatives are employees or representatives of the state or
1680	county, or of anyone other than the entity or the organization
1681	by whom they are reimbursed.
1682	2. False or misleading claims that the entity is
1683	recommended or endorsed by any state or county agency, or by any
1684	other organization which has not certified its endorsement in
1685	writing to the entity.
1686	3. False or misleading claims that the state or county
1687	recommends that a Medicaid recipient enroll with an entity.
1688	4. Claims that a Medicaid recipient will lose benefits
1689	under the Medicaid program, or any other health or welfare
1690	benefits to which the recipient is legally entitled, if the
1691	recipient does not enroll with the entity.
1692	(c) Granting or offering of any monetary or other valuable
1693	consideration for enrollment, except as authorized by subsection
1694	(23) (24).
1695	(d) Door-to-door solicitation of recipients who have not
1696	contacted the entity or who have not invited the entity to make
1697	a presentation.
1698	(e) Solicitation of Medicaid recipients by marketing
1699	representatives stationed in state offices unless approved and
1700	supervised by the agency or its agent and approved by the
1701	affected state agency when solicitation occurs in an office of
1702	the state agency. The agency shall ensure that marketing
1703	representatives stationed in state offices shall market their
1704	managed care plans to Medicaid recipients only in designated
1705	areas and in such a way as to not interfere with the recipients'
1706	activities in the state office.
1707	(f) Enrollment of Medicaid recipients.
1708
1709	This subsection expires October 1, 2013.
1710	(21)(22) The agency may impose a fine for a violation of
1711	this section or the contract with the agency by a person or
1712	entity that is under contract with the agency. With respect to
1713	any nonwillful violation, such fine shall not exceed $2,500 per
1714	violation. In no event shall such fine exceed an aggregate
1715	amount of $10,000 for all nonwillful violations arising out of
1716	the same action. With respect to any knowing and willful
1717	violation of this section or the contract with the agency, the
1718	agency may impose a fine upon the entity in an amount not to
1719	exceed $20,000 for each such violation. In no event shall such
1720	fine exceed an aggregate amount of $100,000 for all knowing and
1721	willful violations arising out of the same action. This
1722	subsection expires October 1, 2013.
1723	(22)(23) A health maintenance organization or a person or
1724	entity exempt from chapter 641 that is under contract with the
1725	agency for the provision of health care services to Medicaid
1726	recipients may not use or distribute marketing materials used to
1727	solicit Medicaid recipients, unless such materials have been
1728	approved by the agency. The provisions of this subsection do not
1729	apply to general advertising and marketing materials used by a
1730	health maintenance organization to solicit both non-Medicaid
1731	subscribers and Medicaid recipients. This subsection expires
1732	October 1, 2013.
1733	(23)(24) Upon approval by the agency, health maintenance
1734	organizations and persons or entities exempt from chapter 641
1735	that are under contract with the agency for the provision of
1736	health care services to Medicaid recipients may be permitted
1737	within the capitation rate to provide additional health benefits
1738	that the agency has found are of high quality, are practicably
1739	available, provide reasonable value to the recipient, and are
1740	provided at no additional cost to the state. This subsection
1741	expires October 1, 2013.
1742	(24)(25) The agency shall utilize the statewide health
1743	maintenance organization complaint hotline for the purpose of
1744	investigating and resolving Medicaid and prepaid health plan
1745	complaints, maintaining a record of complaints and confirmed
1746	problems, and receiving disenrollment requests made by
1747	recipients. This subsection expires October 1, 2013.
1748	(25)(26) The agency shall require the publication of the
1749	health maintenance organization's and the prepaid health plan's
1750	consumer services telephone numbers and the "800" telephone
1751	number of the statewide health maintenance organization
1752	complaint hotline on each Medicaid identification card issued by
1753	a health maintenance organization or prepaid health plan
1754	contracting with the agency to serve Medicaid recipients and on
1755	each subscriber handbook issued to a Medicaid recipient. This
1756	subsection expires October 1, 2013.
1757	(26)(27) The agency shall establish a health care quality
1758	improvement system for those entities contracting with the
1759	agency pursuant to this section, incorporating all the standards
1760	and guidelines developed by the Medicaid Bureau of the Health
1761	Care Financing Administration as a part of the quality assurance
1762	reform initiative. The system shall include, but need not be
1763	limited to, the following:
1764	(a) Guidelines for internal quality assurance programs,
1765	including standards for:
1766	1. Written quality assurance program descriptions.
1767	2. Responsibilities of the governing body for monitoring,
1768	evaluating, and making improvements to care.
1769	3. An active quality assurance committee.
1770	4. Quality assurance program supervision.
1771	5. Requiring the program to have adequate resources to
1772	effectively carry out its specified activities.
1773	6. Provider participation in the quality assurance
1774	program.
1775	7. Delegation of quality assurance program activities.
1776	8. Credentialing and recredentialing.
1777	9. Enrollee rights and responsibilities.
1778	10. Availability and accessibility to services and care.
1779	11. Ambulatory care facilities.
1780	12. Accessibility and availability of medical records, as
1781	well as proper recordkeeping and process for record review.
1782	13. Utilization review.
1783	14. A continuity of care system.
1784	15. Quality assurance program documentation.
1785	16. Coordination of quality assurance activity with other
1786	management activity.
1787	17. Delivering care to pregnant women and infants; to
1788	elderly and disabled recipients, especially those who are at
1789	risk of institutional placement; to persons with developmental
1790	disabilities; and to adults who have chronic, high-cost medical
1791	conditions.
1792	(b) Guidelines which require the entities to conduct
1793	quality-of-care studies which:
1794	1. Target specific conditions and specific health service
1795	delivery issues for focused monitoring and evaluation.
1796	2. Use clinical care standards or practice guidelines to
1797	objectively evaluate the care the entity delivers or fails to
1798	deliver for the targeted clinical conditions and health services
1799	delivery issues.
1800	3. Use quality indicators derived from the clinical care
1801	standards or practice guidelines to screen and monitor care and
1802	services delivered.
1803	(c) Guidelines for external quality review of each
1804	contractor which require: focused studies of patterns of care;
1805	individual care review in specific situations; and followup
1806	activities on previous pattern-of-care study findings and
1807	individual-care-review findings. In designing the external
1808	quality review function and determining how it is to operate as
1809	part of the state's overall quality improvement system, the
1810	agency shall construct its external quality review organization
1811	and entity contracts to address each of the following:
1812	1. Delineating the role of the external quality review
1813	organization.
1814	2. Length of the external quality review organization
1815	contract with the state.
1816	3. Participation of the contracting entities in designing
1817	external quality review organization review activities.
1818	4. Potential variation in the type of clinical conditions
1819	and health services delivery issues to be studied at each plan.
1820	5. Determining the number of focused pattern-of-care
1821	studies to be conducted for each plan.
1822	6. Methods for implementing focused studies.
1823	7. Individual care review.
1824	8. Followup activities.
1825
1826	This subsection expires October 1, 2015.
1827	(27)(28) In order to ensure that children receive health
1828	care services for which an entity has already been compensated,
1829	an entity contracting with the agency pursuant to this section
1830	shall achieve an annual Early and Periodic Screening, Diagnosis,
1831	and Treatment (EPSDT) Service screening rate of at least 60
1832	percent for those recipients continuously enrolled for at least
1833	8 months. The agency shall develop a method by which the EPSDT
1834	screening rate shall be calculated. For any entity which does
1835	not achieve the annual 60 percent rate, the entity must submit a
1836	corrective action plan for the agency's approval. If the entity
1837	does not meet the standard established in the corrective action
1838	plan during the specified timeframe, the agency is authorized to
1839	impose appropriate contract sanctions. At least annually, the
1840	agency shall publicly release the EPSDT Services screening rates
1841	of each entity it has contracted with on a prepaid basis to
1842	serve Medicaid recipients. This subsection expires October 1,
1843	2013.
1844	(28)(29) The agency shall perform enrollments and
1845	disenrollments for Medicaid recipients who are eligible for
1846	MediPass or managed care plans. Notwithstanding the prohibition
1847	contained in paragraph (20)(21)(f), managed care plans may
1848	perform preenrollments of Medicaid recipients under the
1849	supervision of the agency or its agents. For the purposes of
1850	this section, "preenrollment" means the provision of marketing
1851	and educational materials to a Medicaid recipient and assistance
1852	in completing the application forms, but shall not include
1853	actual enrollment into a managed care plan. An application for
1854	enrollment shall not be deemed complete until the agency or its
1855	agent verifies that the recipient made an informed, voluntary
1856	choice. The agency, in cooperation with the Department of
1857	Children and Family Services, may test new marketing initiatives
1858	to inform Medicaid recipients about their managed care options
1859	at selected sites. The agency shall report to the Legislature on
1860	the effectiveness of such initiatives. The agency may contract
1861	with a third party to perform managed care plan and MediPass
1862	enrollment and disenrollment services for Medicaid recipients
1863	and is authorized to adopt rules to implement such services. The
1864	agency may adjust the capitation rate only to cover the costs of
1865	a third-party enrollment and disenrollment contract, and for
1866	agency supervision and management of the managed care plan
1867	enrollment and disenrollment contract. This subsection expires
1868	October 1, 2013.
1869	(29)(30) Any lists of providers made available to Medicaid
1870	recipients, MediPass enrollees, or managed care plan enrollees
1871	shall be arranged alphabetically showing the provider's name and
1872	specialty and, separately, by specialty in alphabetical order.
1873	This subsection expires October 1, 2013.
1874	(30)(31) The agency shall establish an enhanced managed
1875	care quality assurance oversight function, to include at least
1876	the following components:
1877	(a) At least quarterly analysis and followup, including
1878	sanctions as appropriate, of managed care participant
1879	utilization of services.
1880	(b) At least quarterly analysis and followup, including
1881	sanctions as appropriate, of quality findings of the Medicaid
1882	peer review organization and other external quality assurance
1883	programs.
1884	(c) At least quarterly analysis and followup, including
1885	sanctions as appropriate, of the fiscal viability of managed
1886	care plans.
1887	(d) At least quarterly analysis and followup, including
1888	sanctions as appropriate, of managed care participant
1889	satisfaction and disenrollment surveys.
1890	(e) The agency shall conduct regular and ongoing Medicaid
1891	recipient satisfaction surveys.
1892
1893	The analyses and followup activities conducted by the agency
1894	under its enhanced managed care quality assurance oversight
1895	function shall not duplicate the activities of accreditation
1896	reviewers for entities regulated under part III of chapter 641,
1897	but may include a review of the finding of such reviewers. This
1898	subsection expires October 1, 2013.
1899	(31)(32) Each managed care plan that is under contract
1900	with the agency to provide health care services to Medicaid
1901	recipients shall annually conduct a background check with the
1902	Florida Department of Law Enforcement of all persons with
1903	ownership interest of 5 percent or more or executive management
1904	responsibility for the managed care plan and shall submit to the
1905	agency information concerning any such person who has been found
1906	guilty of, regardless of adjudication, or has entered a plea of
1907	nolo contendere or guilty to, any of the offenses listed in s.
1908	435.03. This subsection expires October 1, 2013.
1909	(32)(33) The agency shall, by rule, develop a process
1910	whereby a Medicaid managed care plan enrollee who wishes to
1911	enter hospice care may be disenrolled from the managed care plan
1912	within 24 hours after contacting the agency regarding such
1913	request. The agency rule shall include a methodology for the
1914	agency to recoup managed care plan payments on a pro rata basis
1915	if payment has been made for the enrollment month when
1916	disenrollment occurs. This subsection expires October 1, 2013.
1917	(33)(34) The agency and entities that contract with the
1918	agency to provide health care services to Medicaid recipients
1919	under this section or ss. 409.91211 and 409.9122 must comply
1920	with the provisions of s. 641.513 in providing emergency
1921	services and care to Medicaid recipients and MediPass
1922	recipients. Where feasible, safe, and cost-effective, the agency
1923	shall encourage hospitals, emergency medical services providers,
1924	and other public and private health care providers to work
1925	together in their local communities to enter into agreements or
1926	arrangements to ensure access to alternatives to emergency
1927	services and care for those Medicaid recipients who need
1928	nonemergent care. The agency shall coordinate with hospitals,
1929	emergency medical services providers, private health plans,
1930	capitated managed care networks as established in s. 409.91211,
1931	and other public and private health care providers to implement
1932	the provisions of ss. 395.1041(7), 409.91255(3)(g), 627.6405,
1933	and 641.31097 to develop and implement emergency department
1934	diversion programs for Medicaid recipients. This subsection
1935	expires October 1, 2013.
1936	(34)(35) All entities providing health care services to
1937	Medicaid recipients shall make available, and encourage all
1938	pregnant women and mothers with infants to receive, and provide
1939	documentation in the medical records to reflect, the following:
1940	(a) Healthy Start prenatal or infant screening.
1941	(b) Healthy Start care coordination, when screening or
1942	other factors indicate need.
1943	(c) Healthy Start enhanced services in accordance with the
1944	prenatal or infant screening results.
1945	(d) Immunizations in accordance with recommendations of
1946	the Advisory Committee on Immunization Practices of the United
1947	States Public Health Service and the American Academy of
1948	Pediatrics, as appropriate.
1949	(e) Counseling and services for family planning to all
1950	women and their partners.
1951	(f) A scheduled postpartum visit for the purpose of
1952	voluntary family planning, to include discussion of all methods
1953	of contraception, as appropriate.
1954	(g) Referral to the Special Supplemental Nutrition Program
1955	for Women, Infants, and Children (WIC).
1956
1957	This subsection expires October 1, 2013.
1958	(35)(36) Any entity that provides Medicaid prepaid health
1959	plan services shall ensure the appropriate coordination of
1960	health care services with an assisted living facility in cases
1961	where a Medicaid recipient is both a member of the entity's
1962	prepaid health plan and a resident of the assisted living
1963	facility. If the entity is at risk for Medicaid targeted case
1964	management and behavioral health services, the entity shall
1965	inform the assisted living facility of the procedures to follow
1966	should an emergent condition arise. This subsection expires
1967	October 1, 2013.
1968	(37) The agency may seek and implement federal waivers
1969	necessary to provide for cost-effective purchasing of home
1970	health services, private duty nursing services, transportation,
1971	independent laboratory services, and durable medical equipment
1972	and supplies through competitive bidding pursuant to s. 287.057.
1973	The agency may request appropriate waivers from the federal
1974	Health Care Financing Administration in order to competitively
1975	bid such services. The agency may exclude providers not selected
1976	through the bidding process from the Medicaid provider network.
1977	(36)(38) The agency shall enter into agreements with not-
1978	for-profit organizations based in this state for the purpose of
1979	providing vision screening. This subsection expires October 1,
1980	2013.
1981	(37)(39)(a) The agency shall implement a Medicaid
1982	prescribed-drug spending-control program that includes the
1983	following components:
1984	1. A Medicaid preferred drug list, which shall be a
1985	listing of cost-effective therapeutic options recommended by the
1986	Medicaid Pharmacy and Therapeutics Committee established
1987	pursuant to s. 409.91195 and adopted by the agency for each
1988	therapeutic class on the preferred drug list. At the discretion
1989	of the committee, and when feasible, the preferred drug list
1990	should include at least two products in a therapeutic class. The
1991	agency may post the preferred drug list and updates to the
1992	preferred drug list on an Internet website without following the
1993	rulemaking procedures of chapter 120. Antiretroviral agents are
1994	excluded from the preferred drug list. The agency shall also
1995	limit the amount of a prescribed drug dispensed to no more than
1996	a 34-day supply unless the drug products' smallest marketed
1997	package is greater than a 34-day supply, or the drug is
1998	determined by the agency to be a maintenance drug in which case
1999	a 100-day maximum supply may be authorized. The agency is
2000	authorized to seek any federal waivers necessary to implement
2001	these cost-control programs and to continue participation in the
2002	federal Medicaid rebate program, or alternatively to negotiate
2003	state-only manufacturer rebates. The agency may adopt rules to
2004	implement this subparagraph. The agency shall continue to
2005	provide unlimited contraceptive drugs and items. The agency must
2006	establish procedures to ensure that:
2007	a. There is a response to a request for prior consultation
2008	by telephone or other telecommunication device within 24 hours
2009	after receipt of a request for prior consultation; and
2010	b. A 72-hour supply of the drug prescribed is provided in
2011	an emergency or when the agency does not provide a response
2012	within 24 hours as required by sub-subparagraph a.
2013	2. Reimbursement to pharmacies for Medicaid prescribed
2014	drugs shall be set at the lesser of: the average wholesale price
2015	(AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
2016	plus 4.75 percent, the federal upper limit (FUL), the state
2017	maximum allowable cost (SMAC), or the usual and customary (UAC)
2018	charge billed by the provider.
2019	3. The agency shall develop and implement a process for
2020	managing the drug therapies of Medicaid recipients who are using
2021	significant numbers of prescribed drugs each month. The
2022	management process may include, but is not limited to,
2023	comprehensive, physician-directed medical-record reviews, claims
2024	analyses, and case evaluations to determine the medical
2025	necessity and appropriateness of a patient's treatment plan and
2026	drug therapies. The agency may contract with a private
2027	organization to provide drug-program-management services. The
2028	Medicaid drug benefit management program shall include
2029	initiatives to manage drug therapies for HIV/AIDS patients,
2030	patients using 20 or more unique prescriptions in a 180-day
2031	period, and the top 1,000 patients in annual spending. The
2032	agency shall enroll any Medicaid recipient in the drug benefit
2033	management program if he or she meets the specifications of this
2034	provision and is not enrolled in a Medicaid health maintenance
2035	organization.
2036	4. The agency may limit the size of its pharmacy network
2037	based on need, competitive bidding, price negotiations,
2038	credentialing, or similar criteria. The agency shall give
2039	special consideration to rural areas in determining the size and
2040	location of pharmacies included in the Medicaid pharmacy
2041	network. A pharmacy credentialing process may include criteria
2042	such as a pharmacy's full-service status, location, size,
2043	patient educational programs, patient consultation, disease
2044	management services, and other characteristics. The agency may
2045	impose a moratorium on Medicaid pharmacy enrollment when it is
2046	determined that it has a sufficient number of Medicaid-
2047	participating providers. The agency must allow dispensing
2048	practitioners to participate as a part of the Medicaid pharmacy
2049	network regardless of the practitioner's proximity to any other
2050	entity that is dispensing prescription drugs under the Medicaid
2051	program. A dispensing practitioner must meet all credentialing
2052	requirements applicable to his or her practice, as determined by
2053	the agency.
2054	5. The agency shall develop and implement a program that
2055	requires Medicaid practitioners who prescribe drugs to use a
2056	counterfeit-proof prescription pad for Medicaid prescriptions.
2057	The agency shall require the use of standardized counterfeit-
2058	proof prescription pads by Medicaid-participating prescribers or
2059	prescribers who write prescriptions for Medicaid recipients. The
2060	agency may implement the program in targeted geographic areas or
2061	statewide.
2062	6. The agency may enter into arrangements that require
2063	manufacturers of generic drugs prescribed to Medicaid recipients
2064	to provide rebates of at least 15.1 percent of the average
2065	manufacturer price for the manufacturer's generic products.
2066	These arrangements shall require that if a generic-drug
2067	manufacturer pays federal rebates for Medicaid-reimbursed drugs
2068	at a level below 15.1 percent, the manufacturer must provide a
2069	supplemental rebate to the state in an amount necessary to
2070	achieve a 15.1-percent rebate level.
2071	7. The agency may establish a preferred drug list as
2072	described in this subsection, and, pursuant to the establishment
2073	of such preferred drug list, it is authorized to negotiate
2074	supplemental rebates from manufacturers that are in addition to
2075	those required by Title XIX of the Social Security Act and at no
2076	less than 14 percent of the average manufacturer price as
2077	defined in 42 U.S.C. s. 1936 on the last day of a quarter unless
2078	the federal or supplemental rebate, or both, equals or exceeds
2079	29 percent. There is no upper limit on the supplemental rebates
2080	the agency may negotiate. The agency may determine that specific
2081	products, brand-name or generic, are competitive at lower rebate
2082	percentages. Agreement to pay the minimum supplemental rebate
2083	percentage will guarantee a manufacturer that the Medicaid
2084	Pharmaceutical and Therapeutics Committee will consider a
2085	product for inclusion on the preferred drug list. However, a
2086	pharmaceutical manufacturer is not guaranteed placement on the
2087	preferred drug list by simply paying the minimum supplemental
2088	rebate. Agency decisions will be made on the clinical efficacy
2089	of a drug and recommendations of the Medicaid Pharmaceutical and
2090	Therapeutics Committee, as well as the price of competing
2091	products minus federal and state rebates. The agency is
2092	authorized to contract with an outside agency or contractor to
2093	conduct negotiations for supplemental rebates. For the purposes
2094	of this section, the term "supplemental rebates" means cash
2095	rebates. Effective July 1, 2004, value-added programs as a
2096	substitution for supplemental rebates are prohibited. The agency
2097	is authorized to seek any federal waivers to implement this
2098	initiative.
2099	8. The Agency for Health Care Administration shall expand
2100	home delivery of pharmacy products. To assist Medicaid patients
2101	in securing their prescriptions and reduce program costs, the
2102	agency shall expand its current mail-order-pharmacy diabetes-
2103	supply program to include all generic and brand-name drugs used
2104	by Medicaid patients with diabetes. Medicaid recipients in the
2105	current program may obtain nondiabetes drugs on a voluntary
2106	basis. This initiative is limited to the geographic area covered
2107	by the current contract. The agency may seek and implement any
2108	federal waivers necessary to implement this subparagraph.
2109	9. The agency shall limit to one dose per month any drug
2110	prescribed to treat erectile dysfunction.
2111	10.a. The agency may implement a Medicaid behavioral drug
2112	management system. The agency may contract with a vendor that
2113	has experience in operating behavioral drug management systems
2114	to implement this program. The agency is authorized to seek
2115	federal waivers to implement this program.
2116	b. The agency, in conjunction with the Department of
2117	Children and Family Services, may implement the Medicaid
2118	behavioral drug management system that is designed to improve
2119	the quality of care and behavioral health prescribing practices
2120	based on best practice guidelines, improve patient adherence to
2121	medication plans, reduce clinical risk, and lower prescribed
2122	drug costs and the rate of inappropriate spending on Medicaid
2123	behavioral drugs. The program may include the following
2124	elements:
2125	(I) Provide for the development and adoption of best
2126	practice guidelines for behavioral health-related drugs such as
2127	antipsychotics, antidepressants, and medications for treating
2128	bipolar disorders and other behavioral conditions; translate
2129	them into practice; review behavioral health prescribers and
2130	compare their prescribing patterns to a number of indicators
2131	that are based on national standards; and determine deviations
2132	from best practice guidelines.
2133	(II) Implement processes for providing feedback to and
2134	educating prescribers using best practice educational materials
2135	and peer-to-peer consultation.
2136	(III) Assess Medicaid beneficiaries who are outliers in
2137	their use of behavioral health drugs with regard to the numbers
2138	and types of drugs taken, drug dosages, combination drug
2139	therapies, and other indicators of improper use of behavioral
2140	health drugs.
2141	(IV) Alert prescribers to patients who fail to refill
2142	prescriptions in a timely fashion, are prescribed multiple same-
2143	class behavioral health drugs, and may have other potential
2144	medication problems.
2145	(V) Track spending trends for behavioral health drugs and
2146	deviation from best practice guidelines.
2147	(VI) Use educational and technological approaches to
2148	promote best practices, educate consumers, and train prescribers
2149	in the use of practice guidelines.
2150	(VII) Disseminate electronic and published materials.
2151	(VIII) Hold statewide and regional conferences.
2152	(IX) Implement a disease management program with a model
2153	quality-based medication component for severely mentally ill
2154	individuals and emotionally disturbed children who are high
2155	users of care.
2156	11.a. The agency shall implement a Medicaid prescription
2157	drug management system. The agency may contract with a vendor
2158	that has experience in operating prescription drug management
2159	systems in order to implement this system. Any management system
2160	that is implemented in accordance with this subparagraph must
2161	rely on cooperation between physicians and pharmacists to
2162	determine appropriate practice patterns and clinical guidelines
2163	to improve the prescribing, dispensing, and use of drugs in the
2164	Medicaid program. The agency may seek federal waivers to
2165	implement this program.
2166	b. The drug management system must be designed to improve
2167	the quality of care and prescribing practices based on best
2168	practice guidelines, improve patient adherence to medication
2169	plans, reduce clinical risk, and lower prescribed drug costs and
2170	the rate of inappropriate spending on Medicaid prescription
2171	drugs. The program must:
2172	(I) Provide for the development and adoption of best
2173	practice guidelines for the prescribing and use of drugs in the
2174	Medicaid program, including translating best practice guidelines
2175	into practice; reviewing prescriber patterns and comparing them
2176	to indicators that are based on national standards and practice
2177	patterns of clinical peers in their community, statewide, and
2178	nationally; and determine deviations from best practice
2179	guidelines.
2180	(II) Implement processes for providing feedback to and
2181	educating prescribers using best practice educational materials
2182	and peer-to-peer consultation.
2183	(III) Assess Medicaid recipients who are outliers in their
2184	use of a single or multiple prescription drugs with regard to
2185	the numbers and types of drugs taken, drug dosages, combination
2186	drug therapies, and other indicators of improper use of
2187	prescription drugs.
2188	(IV) Alert prescribers to patients who fail to refill
2189	prescriptions in a timely fashion, are prescribed multiple drugs
2190	that may be redundant or contraindicated, or may have other
2191	potential medication problems.
2192	(V) Track spending trends for prescription drugs and
2193	deviation from best practice guidelines.
2194	(VI) Use educational and technological approaches to
2195	promote best practices, educate consumers, and train prescribers
2196	in the use of practice guidelines.
2197	(VII) Disseminate electronic and published materials.
2198	(VIII) Hold statewide and regional conferences.
2199	(IX) Implement disease management programs in cooperation
2200	with physicians and pharmacists, along with a model quality-
2201	based medication component for individuals having chronic
2202	medical conditions.
2203	12. The agency is authorized to contract for drug rebate
2204	administration, including, but not limited to, calculating
2205	rebate amounts, invoicing manufacturers, negotiating disputes
2206	with manufacturers, and maintaining a database of rebate
2207	collections.
2208	13. The agency may specify the preferred daily dosing form
2209	or strength for the purpose of promoting best practices with
2210	regard to the prescribing of certain drugs as specified in the
2211	General Appropriations Act and ensuring cost-effective
2212	prescribing practices.
2213	14. The agency may require prior authorization for
2214	Medicaid-covered prescribed drugs. The agency may, but is not
2215	required to, prior-authorize the use of a product:
2216	a. For an indication not approved in labeling;
2217	b. To comply with certain clinical guidelines; or
2218	c. If the product has the potential for overuse, misuse,
2219	or abuse.
2220
2221	The agency may require the prescribing professional to provide
2222	information about the rationale and supporting medical evidence
2223	for the use of a drug. The agency may post prior authorization
2224	criteria and protocol and updates to the list of drugs that are
2225	subject to prior authorization on an Internet website without
2226	amending its rule or engaging in additional rulemaking.
2227	15. The agency, in conjunction with the Pharmaceutical and
2228	Therapeutics Committee, may require age-related prior
2229	authorizations for certain prescribed drugs. The agency may
2230	preauthorize the use of a drug for a recipient who may not meet
2231	the age requirement or may exceed the length of therapy for use
2232	of this product as recommended by the manufacturer and approved
2233	by the Food and Drug Administration. Prior authorization may
2234	require the prescribing professional to provide information
2235	about the rationale and supporting medical evidence for the use
2236	of a drug.
2237	16. The agency shall implement a step-therapy prior
2238	authorization approval process for medications excluded from the
2239	preferred drug list. Medications listed on the preferred drug
2240	list must be used within the previous 12 months prior to the
2241	alternative medications that are not listed. The step-therapy
2242	prior authorization may require the prescriber to use the
2243	medications of a similar drug class or for a similar medical
2244	indication unless contraindicated in the Food and Drug
2245	Administration labeling. The trial period between the specified
2246	steps may vary according to the medical indication. The step-
2247	therapy approval process shall be developed in accordance with
2248	the committee as stated in s. 409.91195(7) and (8). A drug
2249	product may be approved without meeting the step-therapy prior
2250	authorization criteria if the prescribing physician provides the
2251	agency with additional written medical or clinical documentation
2252	that the product is medically necessary because:
2253	a. There is not a drug on the preferred drug list to treat
2254	the disease or medical condition which is an acceptable clinical
2255	alternative;
2256	b. The alternatives have been ineffective in the treatment
2257	of the beneficiary's disease; or
2258	c. Based on historic evidence and known characteristics of
2259	the patient and the drug, the drug is likely to be ineffective,
2260	or the number of doses have been ineffective.
2261
2262	The agency shall work with the physician to determine the best
2263	alternative for the patient. The agency may adopt rules waiving
2264	the requirements for written clinical documentation for specific
2265	drugs in limited clinical situations.
2266	17. The agency shall implement a return and reuse program
2267	for drugs dispensed by pharmacies to institutional recipients,
2268	which includes payment of a $5 restocking fee for the
2269	implementation and operation of the program. The return and
2270	reuse program shall be implemented electronically and in a
2271	manner that promotes efficiency. The program must permit a
2272	pharmacy to exclude drugs from the program if it is not
2273	practical or cost-effective for the drug to be included and must
2274	provide for the return to inventory of drugs that cannot be
2275	credited or returned in a cost-effective manner. The agency
2276	shall determine if the program has reduced the amount of
2277	Medicaid prescription drugs which are destroyed on an annual
2278	basis and if there are additional ways to ensure more
2279	prescription drugs are not destroyed which could safely be
2280	reused. The agency's conclusion and recommendations shall be
2281	reported to the Legislature by December 1, 2005.
2282	(b) The agency shall implement this subsection to the
2283	extent that funds are appropriated to administer the Medicaid
2284	prescribed-drug spending-control program. The agency may
2285	contract all or any part of this program to private
2286	organizations.
2287	(c) The agency shall submit quarterly reports to the
2288	Governor, the President of the Senate, and the Speaker of the
2289	House of Representatives which must include, but need not be
2290	limited to, the progress made in implementing this subsection
2291	and its effect on Medicaid prescribed-drug expenditures.
2292	(38)(40) Notwithstanding the provisions of chapter 287,
2293	the agency may, at its discretion, renew a contract or contracts
2294	for fiscal intermediary services one or more times for such
2295	periods as the agency may decide; however, all such renewals may
2296	not combine to exceed a total period longer than the term of the
2297	original contract.
2298	(39)(41) The agency shall provide for the development of a
2299	demonstration project by establishment in Miami-Dade County of a
2300	long-term-care facility licensed pursuant to chapter 395 to
2301	improve access to health care for a predominantly minority,
2302	medically underserved, and medically complex population and to
2303	evaluate alternatives to nursing home care and general acute
2304	care for such population. Such project is to be located in a
2305	health care condominium and colocated with licensed facilities
2306	providing a continuum of care. The establishment of this project
2307	is not subject to the provisions of s. 408.036 or s. 408.039.
2308	This subsection expires October 1, 2012.
2309	(42) The agency shall develop and implement a utilization
2310	management program for Medicaid-eligible recipients for the
2311	management of occupational, physical, respiratory, and speech
2312	therapies. The agency shall establish a utilization program that
2313	may require prior authorization in order to ensure medically
2314	necessary and cost-effective treatments. The program shall be
2315	operated in accordance with a federally approved waiver program
2316	or state plan amendment. The agency may seek a federal waiver or
2317	state plan amendment to implement this program. The agency may
2318	also competitively procure these services from an outside vendor
2319	on a regional or statewide basis.
2320	(40)(43) The agency shall may contract on a prepaid or
2321	fixed-sum basis with appropriately licensed prepaid dental
2322	health plans to provide dental services. This subsection expires
2323	October 1, 2013.
2324	(41)(44) The Agency for Health Care Administration shall
2325	ensure that any Medicaid managed care plan as defined in s.
2326	409.9122(2)(f), whether paid on a capitated basis or a shared
2327	savings basis, is cost-effective. For purposes of this
2328	subsection, the term "cost-effective" means that a network's
2329	per-member, per-month costs to the state, including, but not
2330	limited to, fee-for-service costs, administrative costs, and
2331	case-management fees, if any, must be no greater than the
2332	state's costs associated with contracts for Medicaid services
2333	established under subsection (3), which may be adjusted for
2334	health status. The agency shall conduct actuarially sound
2335	adjustments for health status in order to ensure such cost-
2336	effectiveness and shall publish the results on its Internet
2337	website and submit the results annually to the Governor, the
2338	President of the Senate, and the Speaker of the House of
2339	Representatives no later than December 31 of each year.
2340	Contracts established pursuant to this subsection which are not
2341	cost-effective may not be renewed. This subsection expires
2342	October 1, 2013.
2343	(42)(45) Subject to the availability of funds, the agency
2344	shall mandate a recipient's participation in a provider lock-in
2345	program, when appropriate, if a recipient is found by the agency
2346	to have used Medicaid goods or services at a frequency or amount
2347	not medically necessary, limiting the receipt of goods or
2348	services to medically necessary providers after the 21-day
2349	appeal process has ended, for a period of not less than 1 year.
2350	The lock-in programs shall include, but are not limited to,
2351	pharmacies, medical doctors, and infusion clinics. The
2352	limitation does not apply to emergency services and care
2353	provided to the recipient in a hospital emergency department.
2354	The agency shall seek any federal waivers necessary to implement
2355	this subsection. The agency shall adopt any rules necessary to
2356	comply with or administer this subsection. This subsection
2357	expires October 1, 2013.
2358	(43)(46) The agency shall seek a federal waiver for
2359	permission to terminate the eligibility of a Medicaid recipient
2360	who has been found to have committed fraud, through judicial or
2361	administrative determination, two times in a period of 5 years.
2362	(47) The agency shall conduct a study of available
2363	electronic systems for the purpose of verifying the identity and
2364	eligibility of a Medicaid recipient. The agency shall recommend
2365	to the Legislature a plan to implement an electronic
2366	verification system for Medicaid recipients by January 31, 2005.
2367	(44)(48)(a) A provider is not entitled to enrollment in
2368	the Medicaid provider network. The agency may implement a
2369	Medicaid fee-for-service provider network controls, including,
2370	but not limited to, competitive procurement and provider
2371	credentialing. If a credentialing process is used, the agency
2372	may limit its provider network based upon the following
2373	considerations: beneficiary access to care, provider
2374	availability, provider quality standards and quality assurance
2375	processes, cultural competency, demographic characteristics of
2376	beneficiaries, practice standards, service wait times, provider
2377	turnover, provider licensure and accreditation history, program
2378	integrity history, peer review, Medicaid policy and billing
2379	compliance records, clinical and medical record audit findings,
2380	and such other areas that are considered necessary by the agency
2381	to ensure the integrity of the program.
2382	(b) The agency shall limit its network of durable medical
2383	equipment and medical supply providers. For dates of service
2384	after January 1, 2009, the agency shall limit payment for
2385	durable medical equipment and supplies to providers that meet
2386	all the requirements of this paragraph.
2387	1. Providers must be accredited by a Centers for Medicare
2388	and Medicaid Services deemed accreditation organization for
2389	suppliers of durable medical equipment, prosthetics, orthotics,
2390	and supplies. The provider must maintain accreditation and is
2391	subject to unannounced reviews by the accrediting organization.
2392	2. Providers must provide the services or supplies
2393	directly to the Medicaid recipient or caregiver at the provider
2394	location or recipient's residence or send the supplies directly
2395	to the recipient's residence with receipt of mailed delivery.
2396	Subcontracting or consignment of the service or supply to a
2397	third party is prohibited.
2398	3. Notwithstanding subparagraph 2., a durable medical
2399	equipment provider may store nebulizers at a physician's office
2400	for the purpose of having the physician's staff issue the
2401	equipment if it meets all of the following conditions:
2402	a. The physician must document the medical necessity and
2403	need to prevent further deterioration of the patient's
2404	respiratory status by the timely delivery of the nebulizer in
2405	the physician's office.
2406	b. The durable medical equipment provider must have
2407	written documentation of the competency and training by a
2408	Florida-licensed registered respiratory therapist of any durable
2409	medical equipment staff who participate in the training of
2410	physician office staff for the use of nebulizers, including
2411	cleaning, warranty, and special needs of patients.
2412	c. The physician's office must have documented the
2413	training and competency of any staff member who initiates the
2414	delivery of nebulizers to patients. The durable medical
2415	equipment provider must maintain copies of all physician office
2416	training.
2417	d. The physician's office must maintain inventory records
2418	of stored nebulizers, including documentation of the durable
2419	medical equipment provider source.
2420	e. A physician contracted with a Medicaid durable medical
2421	equipment provider may not have a financial relationship with
2422	that provider or receive any financial gain from the delivery of
2423	nebulizers to patients.
2424	4. Providers must have a physical business location and a
2425	functional landline business phone. The location must be within
2426	the state or not more than 50 miles from the Florida state line.
2427	The agency may make exceptions for providers of durable medical
2428	equipment or supplies not otherwise available from other
2429	enrolled providers located within the state.
2430	5. Physical business locations must be clearly identified
2431	as a business that furnishes durable medical equipment or
2432	medical supplies by signage that can be read from 20 feet away.
2433	The location must be readily accessible to the public during
2434	normal, posted business hours and must operate no less than 5
2435	hours per day and no less than 5 days per week, with the
2436	exception of scheduled and posted holidays. The location may not
2437	be located within or at the same numbered street address as
2438	another enrolled Medicaid durable medical equipment or medical
2439	supply provider or as an enrolled Medicaid pharmacy that is also
2440	enrolled as a durable medical equipment provider. A licensed
2441	orthotist or prosthetist that provides only orthotic or
2442	prosthetic devices as a Medicaid durable medical equipment
2443	provider is exempt from the provisions in this paragraph.
2444	6. Providers must maintain a stock of durable medical
2445	equipment and medical supplies on site that is readily available
2446	to meet the needs of the durable medical equipment business
2447	location's customers.
2448	7. Providers must provide a surety bond of $50,000 for
2449	each provider location, up to a maximum of 5 bonds statewide or
2450	an aggregate bond of $250,000 statewide, as identified by
2451	Federal Employer Identification Number. Providers who post a
2452	statewide or an aggregate bond must identify all of their
2453	locations in any Medicaid durable medical equipment and medical
2454	supply provider enrollment application or bond renewal. Each
2455	provider location's surety bond must be renewed annually and the
2456	provider must submit proof of renewal even if the original bond
2457	is a continuous bond. A licensed orthotist or prosthetist that
2458	provides only orthotic or prosthetic devices as a Medicaid
2459	durable medical equipment provider is exempt from the provisions
2460	in this paragraph.
2461	8. Providers must obtain a level 2 background screening,
2462	as provided under s. 435.04, for each provider employee in
2463	direct contact with or providing direct services to recipients
2464	of durable medical equipment and medical supplies in their
2465	homes. This requirement includes, but is not limited to, repair
2466	and service technicians, fitters, and delivery staff. The
2467	provider shall pay for the cost of the background screening.
2468	9. The following providers are exempt from the
2469	requirements of subparagraphs 1. and 7.:
2470	a. Durable medical equipment providers owned and operated
2471	by a government entity.
2472	b. Durable medical equipment providers that are operating
2473	within a pharmacy that is currently enrolled as a Medicaid
2474	pharmacy provider.
2475	c. Active, Medicaid-enrolled orthopedic physician groups,
2476	primarily owned by physicians, which provide only orthotic and
2477	prosthetic devices.
2478	(45)(49) The agency shall contract with established
2479	minority physician networks that provide services to
2480	historically underserved minority patients. The networks must
2481	provide cost-effective Medicaid services, comply with the
2482	requirements to be a MediPass provider, and provide their
2483	primary care physicians with access to data and other management
2484	tools necessary to assist them in ensuring the appropriate use
2485	of services, including inpatient hospital services and
2486	pharmaceuticals.
2487	(a) The agency shall provide for the development and
2488	expansion of minority physician networks in each service area to
2489	provide services to Medicaid recipients who are eligible to
2490	participate under federal law and rules.
2491	(b) The agency shall reimburse each minority physician
2492	network as a fee-for-service provider, including the case
2493	management fee for primary care, if any, or as a capitated rate
2494	provider for Medicaid services. Any savings shall be shared with
2495	the minority physician networks pursuant to the contract.
2496	(c) For purposes of this subsection, the term "cost-
2497	effective" means that a network's per-member, per-month costs to
2498	the state, including, but not limited to, fee-for-service costs,
2499	administrative costs, and case-management fees, if any, must be
2500	no greater than the state's costs associated with contracts for
2501	Medicaid services established under subsection (3), which shall
2502	be actuarially adjusted for case mix, model, and service area.
2503	The agency shall conduct actuarially sound audits adjusted for
2504	case mix and model in order to ensure such cost-effectiveness
2505	and shall publish the audit results on its Internet website and
2506	submit the audit results annually to the Governor, the President
2507	of the Senate, and the Speaker of the House of Representatives
2508	no later than December 31. Contracts established pursuant to
2509	this subsection which are not cost-effective may not be renewed.
2510	(d) The agency may apply for any federal waivers needed to
2511	implement this subsection.
2512
2513	This subsection expires October 1, 2013.
2514	(46)(50) To the extent permitted by federal law and as
2515	allowed under s. 409.906, the agency shall provide reimbursement
2516	for emergency mental health care services for Medicaid
2517	recipients in crisis stabilization facilities licensed under s.
2518	394.875 as long as those services are less expensive than the
2519	same services provided in a hospital setting.
2520	(47)(51) The agency shall work with the Agency for Persons
2521	with Disabilities to develop a home and community-based waiver
2522	to serve children and adults who are diagnosed with familial
2523	dysautonomia or Riley-Day syndrome caused by a mutation of the
2524	IKBKAP gene on chromosome 9. The agency shall seek federal
2525	waiver approval and implement the approved waiver subject to the
2526	availability of funds and any limitations provided in the
2527	General Appropriations Act. The agency may adopt rules to
2528	implement this waiver program.
2529	(48)(52) The agency shall implement a program of all-
2530	inclusive care for children. The program of all-inclusive care
2531	for children shall be established to provide in-home hospice-
2532	like support services to children diagnosed with a life-
2533	threatening illness and enrolled in the Children's Medical
2534	Services network to reduce hospitalizations as appropriate. The
2535	agency, in consultation with the Department of Health, may
2536	implement the program of all-inclusive care for children after
2537	obtaining approval from the Centers for Medicare and Medicaid
2538	Services.
2539	(49)(53) Before seeking an amendment to the state plan for
2540	purposes of implementing programs authorized by the Deficit
2541	Reduction Act of 2005, the agency shall notify the Legislature.
2542	Section 11. Subsection (4) of section 409.91195, Florida
2543	Statutes, is amended to read:
2544	409.91195 Medicaid Pharmaceutical and Therapeutics
2545	Committee.-There is created a Medicaid Pharmaceutical and
2546	Therapeutics Committee within the agency for the purpose of
2547	developing a Medicaid preferred drug list.
2548	(4) Upon recommendation of the committee, the agency shall
2549	adopt a preferred drug list as described in s. 409.912(37)(39).
2550	To the extent feasible, the committee shall review all drug
2551	classes included on the preferred drug list every 12 months, and
2552	may recommend additions to and deletions from the preferred drug
2553	list, such that the preferred drug list provides for medically
2554	appropriate drug therapies for Medicaid patients which achieve
2555	cost savings contained in the General Appropriations Act.
2556	Section 12. Subsection (1) of section 409.91196, Florida
2557	Statutes, is amended to read:
2558	409.91196 Supplemental rebate agreements; public records
2559	and public meetings exemption.-
2560	(1) The rebate amount, percent of rebate, manufacturer's
2561	pricing, and supplemental rebate, and other trade secrets as
2562	defined in s. 688.002 that the agency has identified for use in
2563	negotiations, held by the Agency for Health Care Administration
2564	under s. 409.912(37)(39)(a)7. are confidential and exempt from
2565	s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
2566	Section 13. Section 409.91207, Florida Statutes, is
2567	amended to read:
2568	(Substantial rewording of section. See s. 409.91207,
2569	F.S., for present text.)
2570	409.91207 Medical homes.-
2571	(1) AUTHORITY.-The agency shall develop a method for
2572	designating qualified plans as a medical home network.
2573	(2) PURPOSE AND PRINCIPLES.-Medical home networks foster
2574	and support coordinated and effective primary care through case
2575	management, support to primary care providers, supplemental
2576	services, and dissemination of best practices. Medical home
2577	networks target patients with chronic illnesses and frequent
2578	service utilization in order to coordinate services, provide
2579	disease management and patient education, and improve quality of
2580	care. In addition to primary care, medical home networks are
2581	able to provide or arrange for pharmacy, outpatient diagnostic,
2582	and specialty physician services and coordinate with inpatient
2583	facilities and rehabilitative service providers.
2584	(3) DESIGNATION.-A qualified plan may request agency
2585	designation as a medical home network if the plan is accredited
2586	as a medical home network by the National Committee for Quality
2587	Assurance or:
2588	(a) The plan establishes a method for its enrollees to
2589	choose to participate as medical home patients and select a
2590	primary care provider that is certified as a medical home.
2591	(b) At least 85 percent of the primary care providers in a
2592	medical home network are certified by the qualified plan as
2593	having the following service capabilities:
2594	1. Supply all medically necessary primary and preventive
2595	services and provide all scheduled immunizations.
2596	2. Organize clinical data in electronic form using a
2597	patient-centered charting system.
2598	3. Maintain and update a patient's medication list and
2599	review all medications during each office visit.
2600	4. Maintain a system to track diagnostic tests and provide
2601	followup services regarding test results.
2602	5. Maintain a system to track referrals, including self-
2603	referrals by members.
2604	6. Supply care coordination and continuity of care through
2605	proactive contact with members and encourage family
2606	participation in care.
2607	7. Supply education and support using various materials
2608	and processes appropriate for individual patient needs.
2609	8. Communicate electronically.
2610	9. Supply voice-to-voice telephone coverage to medical
2611	home patients 24 hours per day, 7 days per week, to enable
2612	medical home patients to speak to a licensed health care
2613	professional who triages and forwards calls, as appropriate.
2614	10. Maintain an office schedule of at least 30 scheduled
2615	hours per week.
2616	11. Use scheduling processes to promote continuity with
2617	clinicians, including providing care for walk-in, routine, and
2618	urgent care visits.
2619	12. Implement and document behavioral health and substance
2620	abuse screening procedures and make referrals as needed.
2621	13. Use data to identify and track patients' health and
2622	service use patterns.
2623	14. Coordinate care and followup for patients receiving
2624	services in inpatient and outpatient facilities.
2625	15. Implement processes to promote access to care and
2626	member communication.
2627	16. Maintain electronic medical records.
2628	17. Develop a health care team that provides ongoing
2629	support, oversight, and guidance for all medical care received
2630	by the patient and documents contact with specialists and other
2631	health care providers caring for the patient.
2632	18. Supply postvisit followup care for patients.
2633	19. Implement specific evidence-based clinical practice
2634	guidelines for preventive and chronic care.
2635	20. Implement a medication reconciliation procedure to
2636	avoid interactions or duplications.
2637	21. Use personalized screening, brief intervention, and
2638	referral to treatment procedures for appropriate patients
2639	requiring specialty treatment.
2640	22. Offer at least 4 hours per week of after-hours care to
2641	patients.
2642	23. Use health assessment tools to identify patient needs
2643	and risks.
2644	(c) The qualified plan offers support services to its
2645	primary care providers, including:
2646	1. Case management, outreach, care coordination, and other
2647	targeted support services for medical home patients.
2648	2. Ongoing assessment of spending and service utilization
2649	by all medical home network patients.
2650	3. Periodic evaluation of patient outcomes.
2651	4. Coordination with inpatient facilities, behavioral
2652	health, and rehabilitative service providers.
2653	5. Establishing specific methods to manage pharmacy and
2654	behavioral health services.
2655	6. Paying primary care providers. It is the intent of the
2656	Legislature that the savings that result from the implementation
2657	of the medical home network model be used to enable Medicaid
2658	fees to physicians participating in medical home networks to be
2659	equivalent to 100 percent of Medicare rates as soon as possible.
2660	(4) AGENCY DUTIES.-The agency shall:
2661	(a) Maintain a record of qualified plans designated as
2662	medical home networks.
2663	(b) Develop a standard form to be used by the qualified
2664	plans to certify to the agency that they meet the necessary
2665	service and primary care provider support capabilities to be
2666	designated a medical home.
2667	Section 14. Section 409.91211, Florida Statutes, is
2668	amended to read:
2669	(Substantial rewording of section. See s. 409.91211,
2670	F.S., for present text.)
2671	409.91211.-Medicaid managed care pilot program.-
2672	(1) AUTHORITY.-The agency is authorized to implement a
2673	managed care pilot program based on the Section 1115 waiver
2674	approved by the Centers for Medicare and Medicaid Services on
2675	October 19, 2005, including continued operation of the program
2676	in Baker, Broward, Clay, Duval, and Nassau Counties. The managed
2677	care pilot program shall be consistent with the provisions of
2678	this section, subject to federal approval.
2679	(2) EXTENSION.-No later than July 1, 2010, the agency
2680	shall begin the process of requesting an extension of the
2681	Section 1115 waiver. The agency shall report at least monthly to
2682	the Legislature on progress in negotiating for the extension of
2683	the waiver. Changes to the terms and conditions relating to the
2684	low-income pool must be approved by the Legislative Budget
2685	Commission.
2686	(3) EXPANSION.-The agency shall expand the managed care
2687	pilot program to Miami-Dade County in a manner that enrolls all
2688	eligible recipients in qualified plan commencing January 1,
2689	2012, but no later than October 1, 2012.
2690	(4) QUALIFIED PLANS.-Managed care plans qualified to
2691	participate in the Medicaid managed care pilot program include
2692	health insurers authorized under chapter 624, exclusive provider
2693	organizations authorized under chapter 627, health maintenance
2694	organizations authorized under chapter 641, the Children's
2695	Medical Services Network under chapter 391, and provider service
2696	networks authorized pursuant to s. 409.912(4)(d).
2697	(5) PLAN REQUIREMENTS.-The agency shall apply the
2698	following requirements to all qualified plans:
2699	(a) Prepaid rates shall be risk adjusted pursuant to
2700	subsection (17).
2701	(b) All Medicaid recipients shall be offered the
2702	opportunity to use their Medicaid premium to pay for the
2703	recipient's share of cost pursuant to s. 409.9122(13).
2704	(6) INTERGOVERNMENTAL TRANSFERS.-In order to preserve
2705	intergovernmental transfers of funds from Miami-Dade County, the
2706	agency shall develop methodologies, including, but not limited
2707	to, a supplemental capitation rate, risk pool, or incentive
2708	payments, which may be paid to prepaid plans or plans owned and
2709	operated by providers that contract with safety net providers,
2710	trauma hospitals, children's hospitals, and statutory teaching
2711	hospitals. In order to preserve certified public expenditures
2712	from Miami-Dade County, the agency shall seek federal approval
2713	to implement a methodology that allows supplemental payments to
2714	be made directly to physicians employed by or under contract
2715	with a medical school in Florida in recognition of the costs
2716	associated with graduate medical education or their teaching
2717	mission. Alternatively, the agency may develop additional
2718	methodologies including, but not limited to, methodologies
2719	mentioned above, as well as capitated rates that exclude
2720	payments made to these physicians so that they may be paid
2721	directly. Once methodologies and payment mechanisms are
2722	approved, the agency shall submit the plan for preserving
2723	intergovernmental transfers and certified public expenditures to
2724	the Legislative Budget Commission. After the assignment and
2725	enrollment of all mandatory eligible persons in Miami-Dade
2726	County into managed care plans, an amendment shall be submitted
2727	to the Legislative Budget Commission requesting authority for
2728	the transfer of sufficient funds from appropriate line items
2729	within the Grants and Donations Trust Fund and the Medical Care
2730	Trust Fund within the Agency for Health Care Administration in
2731	the General Appropriations Act to the line item for Prepaid
2732	Health Plans within the General Appropriations Act. The agency
2733	shall submit a report to the Legislature regarding how the
2734	developed and approved methodologies and payment mechanisms may
2735	be applied to other counties in the state pursuant to managed
2736	care payments under s. 409.968.
2737	(7) ENROLLMENT.-All Medicaid recipients in the counties in
2738	which the managed care pilot program has been implemented shall
2739	be enrolled in a qualified plan. Each recipient shall have a
2740	choice of plans and may select any plan unless that plan is
2741	restricted by contract to a specific population that does not
2742	include the recipient. Medicaid recipients shall have 30 days in
2743	which to make a choice of plans. All recipients shall be offered
2744	choice counseling services in accordance with this section.
2745	(8) CHOICE COUNSELING.-The agency shall provide choice
2746	counseling and may contract for the provision of choice
2747	counseling services. Choice counseling shall be provided in the
2748	native or preferred language of the recipient, consistent with
2749	federal requirements. The agency shall maintain a record of the
2750	recipients who receive such services, identifying the scope and
2751	method of the services provided. The agency shall make available
2752	clear and easily understandable choice information to Medicaid
2753	recipients that includes:
2754	(a) An explanation that each recipient has the right to
2755	choose a qualified plan at the time of enrollment in Medicaid
2756	and again at regular intervals set by the agency and that, if a
2757	recipient does not choose a qualified plan, the agency will
2758	assign the recipient to a qualified plan according to the
2759	criteria specified in this section.
2760	(b) A list and description of the benefits provided in
2761	each plan.
2762	(c) Information about earning credits in the plan's
2763	enhanced benefit program.
2764	(d) An explanation of benefit limits.
2765	(e) Information about cost-sharing requirements of each
2766	plan.
2767	(f) A current list of providers participating in the
2768	network, including location and contact information.
2769	(g) Plan performance data.
2770	(9) AUTOMATIC ENROLLMENT.-The agency shall automatically
2771	enroll Medicaid recipients who do not voluntarily choose a
2772	managed care plan. Enrollment shall be distributed among all
2773	qualified plans. When automatically enrolling recipients, the
2774	agency shall take into account the following criteria:
2775	(a) The plan has sufficient network capacity to meet the
2776	needs of the recipients.
2777	(b) The recipient has previously received services from
2778	one of the plan's primary care providers.
2779	(c) Primary care providers in one plan are more
2780	geographically accessible to the recipient's residence.
2781
2782	The agency may not engage in practices that are designed to
2783	favor one qualified plan over another.
2784	(10) DISENROLLMENT.-After a recipient has selected and
2785	enrolled in a qualified plan, the recipient shall have 90 days
2786	to voluntarily disenroll and select another qualified plan.
2787	After 90 days, further changes may be made only for good cause.
2788	"Good cause" includes, but is not limited to, poor quality of
2789	care, lack of access to necessary specialty services, an
2790	unreasonable delay or denial of service, or fraudulent
2791	enrollment. The agency must make a determination as to whether
2792	cause exists. However, the agency may require a recipient to use
2793	the qualified plan's grievance process prior to the agency's
2794	determination of cause, except in cases in which immediate risk
2795	of permanent damage to the recipient's health is alleged. The
2796	agency must make a determination and take final action on a
2797	recipient's request so that disenrollment occurs no later than
2798	the first day of the second month after the month the request
2799	was made. If the agency fails to act within the specified
2800	timeframe, the recipient's request to disenroll is deemed to be
2801	approved as of the date agency action was required. Recipients
2802	who disagree with the agency's finding that cause does not exist
2803	for disenrollment shall be advised of their right to pursue a
2804	Medicaid fair hearing to dispute the agency's finding.
2805	(11) ENROLLMENT PERIOD.-Medicaid recipients enrolled in a
2806	qualified plan after the 90-day period shall remain in the plan
2807	for 12 months. After 12 months, the recipient may select another
2808	plan. However, nothing shall prevent a Medicaid recipient from
2809	changing primary care providers within the qualified plan during
2810	the 12-month period.
2811	(12) GRIEVANCES.-Each qualified plan shall establish an
2812	internal process for reviewing and responding to grievances from
2813	enrollees. The contract shall specify timeframes for submission,
2814	plan response, and resolution. Grievances not resolved by a
2815	plan's internal process shall be submitted to the Subscriber
2816	Assistance Panel pursuant to s. 408.7056. Each plan shall submit
2817	quarterly reports on the number, description, and outcome of
2818	grievances filed by enrollees. The agency shall establish a
2819	similar process for provider service networks.
2820	(13) BENEFITS.-Qualified plans operating in the Medicaid
2821	managed care pilot program shall cover the services specified in
2822	ss. 409.905 and 409.906, emergency services provided under s.
2823	409.9128, and such other services as the plan may offer. Plans
2824	may customize benefit packages for nonpregnant adults, vary
2825	cost-sharing provisions, and provide coverage for additional
2826	services. The agency shall evaluate the proposed benefit
2827	packages to ensure services are sufficient to meet the needs of
2828	the plans' enrollees and to verify actuarial equivalence.
2829	(14) PENALTIES.-Qualified plans that reduce enrollment
2830	levels or leave a county where the managed care pilot program
2831	has been implemented shall reimburse the agency for the cost of
2832	enrollment changes, including the cost of additional choice
2833	counseling services. When more than one qualified plan leaves a
2834	county at the same time, costs shall be shared by the plans
2835	proportionate to their enrollments.
2836	(15) ACCESS TO DATA.-The agency shall make encounter data
2837	available to those plans accepting enrollees who are assigned to
2838	them from other plans leaving a county where the managed care
2839	pilot program has been implemented.
2840	(16) ENHANCED BENEFITS.-Each plan operating in the managed
2841	care pilot program shall establish an incentive program that
2842	rewards specific healthy behaviors with credits in a flexible
2843	spending account pursuant to s. 409.9122(14).
2844	(17) PAYMENTS TO MANAGED CARE PLANS.-
2845	(a) The agency shall continue the budget-neutral
2846	adjustment of capitation rates for all prepaid plans in existing
2847	managed care pilot program counties.
2848	(b) Beginning September 1, 2010, the agency shall begin a
2849	budget-neutral adjustment of capitation rates for all prepaid
2850	plans in Miami-Dade County. The adjustment to capitation rates
2851	shall be based on aggregate risk scores for each prepaid plan's
2852	enrollees. During the first 2 years of the adjustment, the
2853	agency shall ensure that no plan has an aggregate risk score
2854	that varies by more than 10 percent from the aggregate weighted
2855	average for all plans. Except as otherwise provided in this
2856	paragraph, the risk adjusted capitation rates shall be phased in
2857	as follows:
2858	1. In the first fiscal year, 75 percent of the capitation
2859	rate shall be based on the current methodology and 25 percent
2860	shall be based on the risk-adjusted rate methodology.
2861	2. In the second fiscal year, 50 percent of the capitation
2862	rate shall be based on the current methodology and 50 percent
2863	shall be based on the risk-adjusted methodology.
2864	3. In the third fiscal year, the risk-adjusted capitation
2865	methodology shall be fully implemented.
2866
2867	The rates for plans owned and operated by a public hospital
2868	shall be risk-adjusted immediately. In order to meet the
2869	requirements of budget neutrality, and until such time as all
2870	rates in the county are risk-adjusted, the rate differential is
2871	contingent on the nonfederal share being provided through grants
2872	and donations from allowable nonstate sources. The agency shall
2873	submit an amendment to the Legislative Budget Commission
2874	requesting authority for such payments.
2875	(c) During this period, the agency shall establish a
2876	technical advisory panel to obtain input from the prepaid plans
2877	affected by the transition to risk adjusted rates.
2878	(18) LOW-INCOME POOL.-Funds from a low-income pool shall
2879	be distributed in accordance with the terms and conditions of
2880	the 1115 waiver and in a manner authorized by the General
2881	Appropriations Act. The distribution of funds is intended for
2882	the following purposes:
2883	(a) Assure a broad and fair distribution of available
2884	funds based on the access provided by Medicaid participating
2885	hospitals, regardless of their ownership status, through their
2886	delivery of inpatient or outpatient care for Medicaid
2887	beneficiaries and uninsured and underinsured individuals;
2888	(b) Assure accessible emergency inpatient and outpatient
2889	care for Medicaid beneficiaries and uninsured and underinsured
2890	individuals;
2891	(c) Enhance primary, preventive, and other ambulatory care
2892	coverages for uninsured individuals;
2893	(d) Promote teaching and specialty hospital programs;
2894	(e) Promote the stability and viability of statutorily
2895	defined rural hospitals and hospitals that serve as sole
2896	community hospitals;
2897	(f) Recognize the extent of hospital uncompensated care
2898	costs;
2899	(g) Maintain and enhance essential community hospital
2900	care;
2901	(h) Maintain incentives for local governmental entities to
2902	contribute to the cost of uncompensated care;
2903	(i) Promote measures to avoid preventable
2904	hospitalizations;
2905	(j) Account for hospital efficiency; and
2906	(k) Contribute to a community's overall health system.
2907	(19) ENCOUNTER DATA.-The agency shall maintain and operate
2908	the Medicaid Encounter Data System pursuant to s. 409.9122(15).
2909	(20) EVALUATION.-The agency shall contract with the
2910	University of Florida to complete a comprehensive evaluation of
2911	the managed care pilot program. The evaluation shall include an
2912	assessment of patient satisfaction, changes in benefits and
2913	coverage, implementation and impact of enhanced benefits, access
2914	to care and service utilization by enrolled recipients, and
2915	costs per enrollee. The agency shall establish an initiative to
2916	improve recipient access to information about plan performance.
2917	The agency shall publish on its Internet website information on
2918	plan performance, including, but not limited to, results of plan
2919	enrollee satisfaction surveys, data reported pursuant to s.
2920	409.9122(17), and information on recipient grievances. The
2921	website shall be user-friendly and shall provide an opportunity
2922	for recipients to give web-based feedback on plans. Plans shall
2923	advise recipients of the information available on the agency's
2924	website and how to access it in the initial enrollment
2925	materials. The agency shall evaluate the initiative to determine
2926	whether it improves recipient access to information.
2927	Section 15. Section 409.9122, Florida Statutes, is amended
2928	to read:
2929	409.9122 Mandatory Medicaid managed care enrollment;
2930	programs and procedures.-
2931	(1) It is the intent of the Legislature that the MediPass
2932	program be cost-effective, provide quality health care, and
2933	improve access to health services, and that the program be
2934	statewide. This subsection expires October 1, 2013.
2935	(2)(a) The agency shall enroll in a managed care plan or
2936	MediPass all Medicaid recipients, except those Medicaid
2937	recipients who are: in an institution; enrolled in the Medicaid
2938	medically needy program; or eligible for both Medicaid and
2939	Medicare. Upon enrollment, individuals will be able to change
2940	their managed care option during the 90-day opt out period
2941	required by federal Medicaid regulations. The agency is
2942	authorized to seek the necessary Medicaid state plan amendment
2943	to implement this policy. However, to the extent permitted by
2944	federal law, the agency may enroll in a managed care plan or
2945	MediPass a Medicaid recipient who is exempt from mandatory
2946	managed care enrollment, provided that:
2947	1. The recipient's decision to enroll in a managed care
2948	plan or MediPass is voluntary;
2949	2. If the recipient chooses to enroll in a managed care
2950	plan, the agency has determined that the managed care plan
2951	provides specific programs and services which address the
2952	special health needs of the recipient; and
2953	3. The agency receives any necessary waivers from the
2954	federal Centers for Medicare and Medicaid Services.
2955
2956	The agency shall develop rules to establish policies by which
2957	exceptions to the mandatory managed care enrollment requirement
2958	may be made on a case-by-case basis. The rules shall include the
2959	specific criteria to be applied when making a determination as
2960	to whether to exempt a recipient from mandatory enrollment in a
2961	managed care plan or MediPass. School districts participating in
2962	the certified school match program pursuant to ss. 409.908(21)
2963	and 1011.70 shall be reimbursed by Medicaid, subject to the
2964	limitations of s. 1011.70(1), for a Medicaid-eligible child
2965	participating in the services as authorized in s. 1011.70, as
2966	provided for in s. 409.9071, regardless of whether the child is
2967	enrolled in MediPass or a managed care plan. Managed care plans
2968	shall make a good faith effort to execute agreements with school
2969	districts regarding the coordinated provision of services
2970	authorized under s. 1011.70. County health departments
2971	delivering school-based services pursuant to ss. 381.0056 and
2972	381.0057 shall be reimbursed by Medicaid for the federal share
2973	for a Medicaid-eligible child who receives Medicaid-covered
2974	services in a school setting, regardless of whether the child is
2975	enrolled in MediPass or a managed care plan. Managed care plans
2976	shall make a good faith effort to execute agreements with county
2977	health departments regarding the coordinated provision of
2978	services to a Medicaid-eligible child. To ensure continuity of
2979	care for Medicaid patients, the agency, the Department of
2980	Health, and the Department of Education shall develop procedures
2981	for ensuring that a student's managed care plan or MediPass
2982	provider receives information relating to services provided in
2983	accordance with ss. 381.0056, 381.0057, 409.9071, and 1011.70.
2984	(b) A Medicaid recipient shall not be enrolled in or
2985	assigned to a managed care plan or MediPass unless the managed
2986	care plan or MediPass has complied with the quality-of-care
2987	standards specified in paragraphs (3)(a) and (b), respectively.
2988	(c) Medicaid recipients shall have a choice of managed
2989	care plans or MediPass. The Agency for Health Care
2990	Administration, the Department of Health, the Department of
2991	Children and Family Services, and the Department of Elderly
2992	Affairs shall cooperate to ensure that each Medicaid recipient
2993	receives clear and easily understandable information that meets
2994	the following requirements:
2995	1. Explains the concept of managed care, including
2996	MediPass.
2997	2. Provides information on the comparative performance of
2998	managed care plans and MediPass in the areas of quality,
2999	credentialing, preventive health programs, network size and
3000	availability, and patient satisfaction.
3001	3. Explains where additional information on each managed
3002	care plan and MediPass in the recipient's area can be obtained.
3003	4. Explains that recipients have the right to choose their
3004	managed care coverage at the time they first enroll in Medicaid
3005	and again at regular intervals set by the agency. However, if a
3006	recipient does not choose a managed care plan or MediPass, the
3007	agency will assign the recipient to a managed care plan or
3008	MediPass according to the criteria specified in this section.
3009	5. Explains the recipient's right to complain, file a
3010	grievance, or change managed care plans or MediPass providers if
3011	the recipient is not satisfied with the managed care plan or
3012	MediPass.
3013	(d) The agency shall develop a mechanism for providing
3014	information to Medicaid recipients for the purpose of making a
3015	managed care plan or MediPass selection. Examples of such
3016	mechanisms may include, but not be limited to, interactive
3017	information systems, mailings, and mass marketing materials.
3018	Managed care plans and MediPass providers are prohibited from
3019	providing inducements to Medicaid recipients to select their
3020	plans or from prejudicing Medicaid recipients against other
3021	managed care plans or MediPass providers.
3022	(e) Medicaid recipients who are already enrolled in a
3023	managed care plan or MediPass shall be offered the opportunity
3024	to change managed care plans or MediPass providers on a
3025	staggered basis, as defined by the agency. All Medicaid
3026	recipients shall have 30 days in which to make a choice of
3027	managed care plans or MediPass providers. Those Medicaid
3028	recipients who do not make a choice shall be assigned in
3029	accordance with paragraph (f). To facilitate continuity of care,
3030	for a Medicaid recipient who is also a recipient of Supplemental
3031	Security Income (SSI), prior to assigning the SSI recipient to a
3032	managed care plan or MediPass, the agency shall determine
3033	whether the SSI recipient has an ongoing relationship with a
3034	MediPass provider or managed care plan, and if so, the agency
3035	shall assign the SSI recipient to that MediPass provider or
3036	managed care plan. Those SSI recipients who do not have such a
3037	provider relationship shall be assigned to a managed care plan
3038	or MediPass provider in accordance with paragraph (f).
3039	(f) If a Medicaid recipient does not choose a managed care
3040	plan or MediPass provider, the agency shall assign the Medicaid
3041	recipient to a managed care plan or MediPass provider. Medicaid
3042	recipients eligible for managed care plan enrollment who are
3043	subject to mandatory assignment but who fail to make a choice
3044	shall be assigned to managed care plans until an enrollment of
3045	35 percent in MediPass and 65 percent in managed care plans, of
3046	all those eligible to choose managed care, is achieved. Once
3047	this enrollment is achieved, the assignments shall be divided in
3048	order to maintain an enrollment in MediPass and managed care
3049	plans which is in a 35 percent and 65 percent proportion,
3050	respectively. Thereafter, assignment of Medicaid recipients who
3051	fail to make a choice shall be based proportionally on the
3052	preferences of recipients who have made a choice in the previous
3053	period. Such proportions shall be revised at least quarterly to
3054	reflect an update of the preferences of Medicaid recipients. The
3055	agency shall disproportionately assign Medicaid-eligible
3056	recipients who are required to but have failed to make a choice
3057	of managed care plan or MediPass, including children, and who
3058	would be assigned to the MediPass program to children's networks
3059	as described in s. 409.912(4)(g), Children's Medical Services
3060	Network as defined in s. 391.021, exclusive provider
3061	organizations, provider service networks, minority physician
3062	networks, and pediatric emergency department diversion programs
3063	authorized by this chapter or the General Appropriations Act, in
3064	such manner as the agency deems appropriate, until the agency
3065	has determined that the networks and programs have sufficient
3066	numbers to be operated economically. For purposes of this
3067	paragraph, when referring to assignment, the term "managed care
3068	plans" includes health maintenance organizations, exclusive
3069	provider organizations, provider service networks, minority
3070	physician networks, Children's Medical Services Network, and
3071	pediatric emergency department diversion programs authorized by
3072	this chapter or the General Appropriations Act. When making
3073	assignments, the agency shall take into account the following
3074	criteria:
3075	1. A managed care plan has sufficient network capacity to
3076	meet the need of members.
3077	2. The managed care plan or MediPass has previously
3078	enrolled the recipient as a member, or one of the managed care
3079	plan's primary care providers or MediPass providers has
3080	previously provided health care to the recipient.
3081	3. The agency has knowledge that the member has previously
3082	expressed a preference for a particular managed care plan or
3083	MediPass provider as indicated by Medicaid fee-for-service
3084	claims data, but has failed to make a choice.
3085	4. The managed care plan's or MediPass primary care
3086	providers are geographically accessible to the recipient's
3087	residence.
3088	(g) When more than one managed care plan or MediPass
3089	provider meets the criteria specified in paragraph (f), the
3090	agency shall make recipient assignments consecutively by family
3091	unit.
3092	(h) The agency may not engage in practices that are
3093	designed to favor one managed care plan over another or that are
3094	designed to influence Medicaid recipients to enroll in MediPass
3095	rather than in a managed care plan or to enroll in a managed
3096	care plan rather than in MediPass. This subsection does not
3097	prohibit the agency from reporting on the performance of
3098	MediPass or any managed care plan, as measured by performance
3099	criteria developed by the agency.
3100	(i) After a recipient has made his or her selection or has
3101	been enrolled in a managed care plan or MediPass, the recipient
3102	shall have 90 days to exercise the opportunity to voluntarily
3103	disenroll and select another managed care plan or MediPass.
3104	After 90 days, no further changes may be made except for good
3105	cause. Good cause includes, but is not limited to, poor quality
3106	of care, lack of access to necessary specialty services, an
3107	unreasonable delay or denial of service, or fraudulent
3108	enrollment. The agency shall develop criteria for good cause
3109	disenrollment for chronically ill and disabled populations who
3110	are assigned to managed care plans if more appropriate care is
3111	available through the MediPass program. The agency must make a
3112	determination as to whether cause exists. However, the agency
3113	may require a recipient to use the managed care plan's or
3114	MediPass grievance process prior to the agency's determination
3115	of cause, except in cases in which immediate risk of permanent
3116	damage to the recipient's health is alleged. The grievance
3117	process, when utilized, must be completed in time to permit the
3118	recipient to disenroll by the first day of the second month
3119	after the month the disenrollment request was made. If the
3120	managed care plan or MediPass, as a result of the grievance
3121	process, approves an enrollee's request to disenroll, the agency
3122	is not required to make a determination in the case. The agency
3123	must make a determination and take final action on a recipient's
3124	request so that disenrollment occurs no later than the first day
3125	of the second month after the month the request was made. If the
3126	agency fails to act within the specified timeframe, the
3127	recipient's request to disenroll is deemed to be approved as of
3128	the date agency action was required. Recipients who disagree
3129	with the agency's finding that cause does not exist for
3130	disenrollment shall be advised of their right to pursue a
3131	Medicaid fair hearing to dispute the agency's finding.
3132	(j) The agency shall apply for a federal waiver from the
3133	Centers for Medicare and Medicaid Services to lock eligible
3134	Medicaid recipients into a managed care plan or MediPass for 12
3135	months after an open enrollment period. After 12 months'
3136	enrollment, a recipient may select another managed care plan or
3137	MediPass provider. However, nothing shall prevent a Medicaid
3138	recipient from changing primary care providers within the
3139	managed care plan or MediPass program during the 12-month
3140	period.
3141	(k) When a Medicaid recipient does not choose a managed
3142	care plan or MediPass provider, the agency shall assign the
3143	Medicaid recipient to a managed care plan, except in those
3144	counties in which there are fewer than two managed care plans
3145	accepting Medicaid enrollees, in which case assignment shall be
3146	to a managed care plan or a MediPass provider. Medicaid
3147	recipients in counties with fewer than two managed care plans
3148	accepting Medicaid enrollees who are subject to mandatory
3149	assignment but who fail to make a choice shall be assigned to
3150	managed care plans until an enrollment of 35 percent in MediPass
3151	and 65 percent in managed care plans, of all those eligible to
3152	choose managed care, is achieved. Once that enrollment is
3153	achieved, the assignments shall be divided in order to maintain
3154	an enrollment in MediPass and managed care plans which is in a
3155	35 percent and 65 percent proportion, respectively. For purposes
3156	of this paragraph, when referring to assignment, the term
3157	"managed care plans" includes exclusive provider organizations,
3158	provider service networks, Children's Medical Services Network,
3159	minority physician networks, and pediatric emergency department
3160	diversion programs authorized by this chapter or the General
3161	Appropriations Act. When making assignments, the agency shall
3162	take into account the following criteria:
3163	1. A managed care plan has sufficient network capacity to
3164	meet the need of members.
3165	2. The managed care plan or MediPass has previously
3166	enrolled the recipient as a member, or one of the managed care
3167	plan's primary care providers or MediPass providers has
3168	previously provided health care to the recipient.
3169	3. The agency has knowledge that the member has previously
3170	expressed a preference for a particular managed care plan or
3171	MediPass provider as indicated by Medicaid fee-for-service
3172	claims data, but has failed to make a choice.
3173	4. The managed care plan's or MediPass primary care
3174	providers are geographically accessible to the recipient's
3175	residence.
3176	5. The agency has authority to make mandatory assignments
3177	based on quality of service and performance of managed care
3178	plans.
3179	(l) Notwithstanding the provisions of chapter 287, the
3180	agency may, at its discretion, renew cost-effective contracts
3181	for choice counseling services once or more for such periods as
3182	the agency may decide. However, all such renewals may not
3183	combine to exceed a total period longer than the term of the
3184	original contract.
3185
3186	This subsection expires October 1, 2013.
3187	(3)(a) The agency shall establish quality-of-care
3188	standards for managed care plans. These standards shall be based
3189	upon, but are not limited to:
3190	1. Compliance with the accreditation requirements as
3191	provided in s. 641.512.
3192	2. Compliance with Early and Periodic Screening,
3193	Diagnosis, and Treatment screening requirements.
3194	3. The percentage of voluntary disenrollments.
3195	4. Immunization rates.
3196	5. Standards of the National Committee for Quality
3197	Assurance and other approved accrediting bodies.
3198	6. Recommendations of other authoritative bodies.
3199	7. Specific requirements of the Medicaid program, or
3200	standards designed to specifically assist the unique needs of
3201	Medicaid recipients.
3202	8. Compliance with the health quality improvement system
3203	as established by the agency, which incorporates standards and
3204	guidelines developed by the Medicaid Bureau of the Health Care
3205	Financing Administration as part of the quality assurance reform
3206	initiative.
3207	(b) For the MediPass program, the agency shall establish
3208	standards which are based upon, but are not limited to:
3209	1. Quality-of-care standards which are comparable to those
3210	required of managed care plans.
3211	2. Credentialing standards for MediPass providers.
3212	3. Compliance with Early and Periodic Screening,
3213	Diagnosis, and Treatment screening requirements.
3214	4. Immunization rates.
3215	5. Specific requirements of the Medicaid program, or
3216	standards designed to specifically assist the unique needs of
3217	Medicaid recipients.
3218
3219	This subsection expires October 1, 2013.
3220	(4)(a) Each female recipient may select as her primary
3221	care provider an obstetrician/gynecologist who has agreed to
3222	participate as a MediPass primary care case manager.
3223	(b) The agency shall establish a complaints and grievance
3224	process to assist Medicaid recipients enrolled in the MediPass
3225	program to resolve complaints and grievances. The agency shall
3226	investigate reports of quality-of-care grievances which remain
3227	unresolved to the satisfaction of the enrollee.
3228
3229	This subsection expires October 1, 2013.
3230	(5)(a) The agency shall work cooperatively with the Social
3231	Security Administration to identify beneficiaries who are
3232	jointly eligible for Medicare and Medicaid and shall develop
3233	cooperative programs to encourage these beneficiaries to enroll
3234	in a Medicare participating health maintenance organization or
3235	prepaid health plans.
3236	(b) The agency shall work cooperatively with the
3237	Department of Elderly Affairs to assess the potential cost-
3238	effectiveness of providing MediPass to beneficiaries who are
3239	jointly eligible for Medicare and Medicaid on a voluntary choice
3240	basis. If the agency determines that enrollment of these
3241	beneficiaries in MediPass has the potential for being cost-
3242	effective for the state, the agency shall offer MediPass to
3243	these beneficiaries on a voluntary choice basis in the counties
3244	where MediPass operates.
3245
3246	This subsection expires October 1, 2013.
3247	(6) MediPass enrolled recipients may receive up to 10
3248	visits of reimbursable services by participating Medicaid
3249	physicians licensed under chapter 460 and up to four visits of
3250	reimbursable services by participating Medicaid physicians
3251	licensed under chapter 461. Any further visits must be by prior
3252	authorization by the MediPass primary care provider. However,
3253	nothing in this subsection may be construed to increase the
3254	total number of visits or the total amount of dollars per year
3255	per person under current Medicaid rules, unless otherwise
3256	provided for in the General Appropriations Act. This subsection
3257	expires October 1, 2013.
3258	(7) The agency shall investigate the feasibility of
3259	developing managed care plan and MediPass options for the
3260	following groups of Medicaid recipients:
3261	(a) Pregnant women and infants.
3262	(b) Elderly and disabled recipients, especially those who
3263	are at risk of nursing home placement.
3264	(c) Persons with developmental disabilities.
3265	(d) Qualified Medicare beneficiaries.
3266	(e) Adults who have chronic, high-cost medical conditions.
3267	(f) Adults and children who have mental health problems.
3268	(g) Other recipients for whom managed care plans and
3269	MediPass offer the opportunity of more cost-effective care and
3270	greater access to qualified providers.
3271	(8)(a) The agency shall encourage the development of
3272	public and private partnerships to foster the growth of health
3273	maintenance organizations and prepaid health plans that will
3274	provide high-quality health care to Medicaid recipients.
3275	(b) Subject to the availability of moneys and any
3276	limitations established by the General Appropriations Act or
3277	chapter 216, the agency is authorized to enter into contracts
3278	with traditional providers of health care to low-income persons
3279	to assist such providers with the technical aspects of
3280	cooperatively developing Medicaid prepaid health plans.
3281	1. The agency may contract with disproportionate share
3282	hospitals, county health departments, federally initiated or
3283	federally funded community health centers, and counties that
3284	operate either a hospital or a community clinic.
3285	2. A contract may not be for more than $100,000 per year,
3286	and no contract may be extended with any particular provider for
3287	more than 2 years. The contract is intended only as seed or
3288	development funding and requires a commitment from the
3289	interested party.
3290	3. A contract must require participation by at least one
3291	community health clinic and one disproportionate share hospital.
3292	(7)(9)(a) The agency shall develop and implement a
3293	comprehensive plan to ensure that recipients are adequately
3294	informed of their choices and rights under all Medicaid managed
3295	care programs and that Medicaid managed care programs meet
3296	acceptable standards of quality in patient care, patient
3297	satisfaction, and financial solvency.
3298	(b) The agency shall provide adequate means for informing
3299	patients of their choice and rights under a managed care plan at
3300	the time of eligibility determination.
3301	(c) The agency shall require managed care plans and
3302	MediPass providers to demonstrate and document plans and
3303	activities, as defined by rule, including outreach and followup,
3304	undertaken to ensure that Medicaid recipients receive the health
3305	care service to which they are entitled.
3306
3307	This subsection expires October 1, 2013.
3308	(8)(10) The agency shall consult with Medicaid consumers
3309	and their representatives on an ongoing basis regarding
3310	measurements of patient satisfaction, procedures for resolving
3311	patient grievances, standards for ensuring quality of care,
3312	mechanisms for providing patient access to services, and
3313	policies affecting patient care. This subsection expires October
3314	1, 2013.
3315	(9)(11) The agency may extend eligibility for Medicaid
3316	recipients enrolled in licensed and accredited health
3317	maintenance organizations for the duration of the enrollment
3318	period or for 6 months, whichever is earlier, provided the
3319	agency certifies that such an offer will not increase state
3320	expenditures. This subsection expires October 1, 2013.
3321	(10)(12) A managed care plan that has a Medicaid contract
3322	shall at least annually review each primary care physician's
3323	active patient load and shall ensure that additional Medicaid
3324	recipients are not assigned to physicians who have a total
3325	active patient load of more than 3,000 patients. As used in this
3326	subsection, the term "active patient" means a patient who is
3327	seen by the same primary care physician, or by a physician
3328	assistant or advanced registered nurse practitioner under the
3329	supervision of the primary care physician, at least three times
3330	within a calendar year. Each primary care physician shall
3331	annually certify to the managed care plan whether or not his or
3332	her patient load exceeds the limits established under this
3333	subsection and the managed care plan shall accept such
3334	certification on face value as compliance with this subsection.
3335	The agency shall accept the managed care plan's representations
3336	that it is in compliance with this subsection based on the
3337	certification of its primary care physicians, unless the agency
3338	has an objective indication that access to primary care is being
3339	compromised, such as receiving complaints or grievances relating
3340	to access to care. If the agency determines that an objective
3341	indication exists that access to primary care is being
3342	compromised, it may verify the patient load certifications
3343	submitted by the managed care plan's primary care physicians and
3344	that the managed care plan is not assigning Medicaid recipients
3345	to primary care physicians who have an active patient load of
3346	more than 3,000 patients. This subsection expires October 1,
3347	2013.
3348	(13) Effective July 1, 2003, the agency shall adjust the
3349	enrollee assignment process of Medicaid managed prepaid health
3350	plans for those Medicaid managed prepaid plans operating in
3351	Miami-Dade County which have executed a contract with the agency
3352	for a minimum of 8 consecutive years in order for the Medicaid
3353	managed prepaid plan to maintain a minimum enrollment level of
3354	15,000 members per month. When assigning enrollees pursuant to
3355	this subsection, the agency shall give priority to providers
3356	that initially qualified under this subsection until such
3357	providers reach and maintain an enrollment level of 15,000
3358	members per month. A prepaid health plan that has a statewide
3359	Medicaid enrollment of 25,000 or more members is not eligible
3360	for enrollee assignments under this subsection.
3361	(11)(14) The agency shall include in its calculation of
3362	the hospital inpatient component of a Medicaid health
3363	maintenance organization's capitation rate any special payments,
3364	including, but not limited to, upper payment limit or
3365	disproportionate share hospital payments, made to qualifying
3366	hospitals through the fee-for-service program. The agency may
3367	seek federal waiver approval or state plan amendment as needed
3368	to implement this adjustment.
3369	(12)(a) Beginning September 1, 2010, the agency shall
3370	begin a budget-neutral adjustment of capitation rates for all
3371	Medicaid prepaid plans in the state. The adjustment to
3372	capitation rates shall be based on aggregate risk scores for
3373	each prepaid plan's enrollees. During the first 2 years of the
3374	adjustment, the agency shall ensure that no plan has an
3375	aggregate risk score that varies more than 10 percent from the
3376	aggregate weighted average for all plans. The risk adjusted
3377	capitation rates shall be phased in as follows:
3378	1. In the first fiscal year, 75 percent of the capitation
3379	rate shall be based on the current methodology and 25 percent
3380	shall be based on the risk-adjusted rate methodology.
3381	2. In the second fiscal year, 50 percent of the capitation
3382	rate shall be based on the current methodology and 50 percent
3383	shall be based on the risk-adjusted methodology.
3384	3. In the third fiscal year, the risk-adjusted capitation
3385	methodology shall be fully implemented.
3386	(b) During this period, the agency shall establish a
3387	technical advisory panel to obtain input from the prepaid plans
3388	affected by the transition to risk adjusted rates.
3389	(13) The agency shall develop a process to enable any
3390	recipient with access to employer sponsored insurance to opt out
3391	of all qualified plans in the Medicaid program and to use
3392	Medicaid financial assistance to pay for the recipient's share
3393	of cost in any such plan. Contingent on federal approval, the
3394	agency shall also enable recipients with access to other
3395	insurance or related products providing access to health care
3396	services created pursuant to state law, including any plan or
3397	product available pursuant to Cover Florida, the Florida Health
3398	Choices Program, or any health exchange, to opt out. The amount
3399	of financial assistance provided for each recipient shall not
3400	exceed the amount of the Medicaid premium that would have been
3401	paid to a plan for that recipient.
3402	(14) Each qualified plan shall establish an incentive
3403	program that rewards specific healthy behaviors with credits in
3404	a flexible spending account pursuant to s. 409.9122(14).
3405	(a) At the discretion of the recipient, credits shall be
3406	used to purchase otherwise uncovered health and related services
3407	during the entire period of and for a maximum of 3 years after
3408	the recipient's Medicaid eligibility, whether or not the
3409	recipient remains continuously enrolled in the plan in which the
3410	credits were earned.
3411	(b) Enhanced benefits offered by a qualified plan shall be
3412	structured to provide greater incentives for those diseases
3413	linked with lifestyle and conditions or behaviors associated
3414	with avoidable utilization of high-cost services.
3415	(c) To fund these credits, each plan must maintain a
3416	reserve account in an amount up to 2 percent of the plan's
3417	Medicaid premium revenue or benchmark premium revenue in the
3418	case of provider service networks based on an actuarial
3419	assessment of the value of the enhanced benefit program.
3420	(15) The agency shall maintain and operate the Medicaid
3421	Encounter Data System to collect, process, store, and report on
3422	covered services provided to all Florida Medicaid recipients
3423	enrolled in prepaid managed care plans. Prepaid managed care
3424	plans shall submit encounter data electronically in a format
3425	that complies with the Health Insurance Portability and
3426	Accountability Act provisions for electronic claims and in
3427	accordance with deadlines established by the agency. Prepaid
3428	managed care plans must certify that the data reported is
3429	accurate and complete. The agency is responsible for validating
3430	the data submitted by the plans. Prior to utilizing validated
3431	encounter data to adjust rates for prepaid plans, the agency
3432	shall conduct a review to ensure adequate encounter data is
3433	available to establish actuarially sound rates. The review shall
3434	include a simulated rate-setting exercise, followed by an
3435	evaluation by independent actuaries and consideration of
3436	comments from the plans. The agency shall publish the results of
3437	the review on its website at least 30 days prior to adjusting
3438	rates.
3439	(16) The agency may establish a per-member per-month
3440	payment for Medicare Advantage Special Needs members that are
3441	also eligible for Medicaid as a mechanism for meeting the
3442	state's cost sharing obligation. The agency may also develop a
3443	per-member per-month payment for Medicaid only covered services
3444	for which the state is responsible. The agency shall develop a
3445	mechanism to ensure that such per-member per-month payment
3446	enhances the value to the state and enrolled members by limiting
3447	cost sharing, enhancing the scope of Medicare supplemental
3448	benefits that are equal to or greater than Medicaid coverage for
3449	select services, and improving care coordination.
3450	(17) The agency shall establish, and managed care plans
3451	shall use, a uniform method of accounting for and reporting
3452	medical and nonmedical costs. The agency shall make such
3453	information available to the public.
3454	(18) Effective October 1, 2013, school districts
3455	participating in the certified school match program pursuant to
3456	ss. 409.908(21) and 1011.70 shall be reimbursed by Medicaid,
3457	subject to the limitations of s. 1011.70(1), for a Medicaid-
3458	eligible child participating in the services as authorized in s.
3459	1011.70, as provided for in s. 409.9071. Managed care plans
3460	shall make a good faith effort to execute agreements with school
3461	districts regarding the coordinated provision of services
3462	authorized under s. 1011.70 and county health departments
3463	delivering school-based services pursuant to ss. 381.0056 and
3464	381.0057. To ensure continuity of care for Medicaid patients,
3465	the agency, the Department of Health, and the Department of
3466	Education shall develop procedures for ensuring that a student's
3467	managed care plan receives information relating to services
3468	provided in accordance with ss. 381.0056, 381.0057, 409.9071,
3469	and 1011.70.
3470	(19) The agency may, on a case-by-case basis, exempt a
3471	recipient from mandatory enrollment in a managed care plan when
3472	the recipient has a unique, time-limited disease or condition-
3473	related circumstance and managed care enrollment will interfere
3474	with ongoing care because the recipient's provider does not
3475	participate in the managed care plans available in the
3476	recipient's area.
3477	Section 16. Subsection (18) of section 430.04, Florida
3478	Statutes, is amended to read:
3479	430.04 Duties and responsibilities of the Department of
3480	Elderly Affairs.-The Department of Elderly Affairs shall:
3481	(18) Administer all Medicaid waivers and programs relating
3482	to elders and their appropriations. The waivers include, but are
3483	not limited to:
3484	(a) The Alzheimer's Dementia-Specific Medicaid Waiver as
3485	established in s. 430.502(7), (8), and (9).
3486	(a)(b) The Assisted Living for the Frail Elderly Waiver.
3487	(b)(c) The Aged and Disabled Adult Waiver.
3488	(c)(d) The Adult Day Health Care Waiver.
3489	(d)(e) The Consumer-Directed Care Plus Program as defined
3490	in s. 409.221.
3491	(e)(f) The Program of All-inclusive Care for the Elderly.
3492	(f)(g) The Long-Term Care Community-Based Diversion Pilot
3493	Project as described in s. 430.705.
3494	(g)(h) The Channeling Services Waiver for Frail Elders.
3495
3496	The department shall develop a transition plan for recipients
3497	receiving services in long-term care Medicaid waivers for elders
3498	or disabled adults on the date qualified plans become available
3499	in each recipient's region pursuant to s. 409.981(2) to enroll
3500	those recipients in qualified plans. This subsection expires
3501	October 1, 2012.
3502	Section 17. Section 430.2053, Florida Statutes, is amended
3503	to read:
3504	430.2053 Aging resource centers.-
3505	(1) The department, in consultation with the Agency for
3506	Health Care Administration and the Department of Children and
3507	Family Services, shall develop pilot projects for aging resource
3508	centers. By October 31, 2004, the department, in consultation
3509	with the agency and the Department of Children and Family
3510	Services, shall develop an implementation plan for aging
3511	resource centers and submit the plan to the Governor, the
3512	President of the Senate, and the Speaker of the House of
3513	Representatives. The plan must include qualifications for
3514	designation as a center, the functions to be performed by each
3515	center, and a process for determining that a current area agency
3516	on aging is ready to assume the functions of an aging resource
3517	center.
3518	(2) Each area agency on aging shall develop, in
3519	consultation with the existing community care for the elderly
3520	lead agencies within their planning and service areas, a
3521	proposal that describes the process the area agency on aging
3522	intends to undertake to transition to an aging resource center
3523	prior to July 1, 2005, and that describes the area agency's
3524	compliance with the requirements of this section. The proposals
3525	must be submitted to the department prior to December 31, 2004.
3526	The department shall evaluate all proposals for readiness and,
3527	prior to March 1, 2005, shall select three area agencies on
3528	aging which meet the requirements of this section to begin the
3529	transition to aging resource centers. Those area agencies on
3530	aging which are not selected to begin the transition to aging
3531	resource centers shall, in consultation with the department and
3532	the existing community care for the elderly lead agencies within
3533	their planning and service areas, amend their proposals as
3534	necessary and resubmit them to the department prior to July 1,
3535	2005. The department may transition additional area agencies to
3536	aging resource centers as it determines that area agencies are
3537	in compliance with the requirements of this section.
3538	(3) The Auditor General and the Office of Program Policy
3539	Analysis and Government Accountability (OPPAGA) shall jointly
3540	review and assess the department's process for determining an
3541	area agency's readiness to transition to an aging resource
3542	center.
3543	(a) The review must, at a minimum, address the
3544	appropriateness of the department's criteria for selection of an
3545	area agency to transition to an aging resource center, the
3546	instruments applied, the degree to which the department
3547	accurately determined each area agency's compliance with the
3548	readiness criteria, the quality of the technical assistance
3549	provided by the department to an area agency in correcting any
3550	weaknesses identified in the readiness assessment, and the
3551	degree to which each area agency overcame any identified
3552	weaknesses.
3553	(b) Reports of these reviews must be submitted to the
3554	appropriate substantive and appropriations committees in the
3555	Senate and the House of Representatives on March 1 and September
3556	1 of each year until full transition to aging resource centers
3557	has been accomplished statewide, except that the first report
3558	must be submitted by February 1, 2005, and must address all
3559	readiness activities undertaken through December 31, 2004. The
3560	perspectives of all participants in this review process must be
3561	included in each report.
3562	(2)(4) The purposes of an aging resource center shall be:
3563	(a) To provide Florida's elders and their families with a
3564	locally focused, coordinated approach to integrating information
3565	and referral for all available services for elders with the
3566	eligibility determination entities for state and federally
3567	funded long-term-care services.
3568	(b) To provide for easier access to long-term-care
3569	services by Florida's elders and their families by creating
3570	multiple access points to the long-term-care network that flow
3571	through one established entity with wide community recognition.
3572	(3)(5) The duties of an aging resource center are to:
3573	(a) Develop referral agreements with local community
3574	service organizations, such as senior centers, existing elder
3575	service providers, volunteer associations, and other similar
3576	organizations, to better assist clients who do not need or do
3577	not wish to enroll in programs funded by the department or the
3578	agency. The referral agreements must also include a protocol,
3579	developed and approved by the department, which provides
3580	specific actions that an aging resource center and local
3581	community service organizations must take when an elder or an
3582	elder's representative seeking information on long-term-care
3583	services contacts a local community service organization prior
3584	to contacting the aging resource center. The protocol shall be
3585	designed to ensure that elders and their families are able to
3586	access information and services in the most efficient and least
3587	cumbersome manner possible.
3588	(b) Provide an initial screening of all clients who
3589	request long-term-care services to determine whether the person
3590	would be most appropriately served through any combination of
3591	federally funded programs, state-funded programs, locally funded
3592	or community volunteer programs, or private funding for
3593	services.
3594	(c) Determine eligibility for the programs and services
3595	listed in subsection (9) (11) for persons residing within the
3596	geographic area served by the aging resource center and
3597	determine a priority ranking for services which is based upon
3598	the potential recipient's frailty level and likelihood of
3599	institutional placement without such services.
3600	(d) Manage the availability of financial resources for the
3601	programs and services listed in subsection (9) (11) for persons
3602	residing within the geographic area served by the aging resource
3603	center.
3604	(e) When financial resources become available, refer a
3605	client to the most appropriate entity to begin receiving
3606	services. The aging resource center shall make referrals to lead
3607	agencies for service provision that ensure that individuals who
3608	are vulnerable adults in need of services pursuant to s.
3609	415.104(3)(b), or who are victims of abuse, neglect, or
3610	exploitation in need of immediate services to prevent further
3611	harm and are referred by the adult protective services program,
3612	are given primary consideration for receiving community-care-
3613	for-the-elderly services in compliance with the requirements of
3614	s. 430.205(5)(a) and that other referrals for services are in
3615	compliance with s. 430.205(5)(b).
3616	(f) Convene a work group to advise in the planning,
3617	implementation, and evaluation of the aging resource center. The
3618	work group shall be comprised of representatives of local
3619	service providers, Alzheimer's Association chapters, housing
3620	authorities, social service organizations, advocacy groups,
3621	representatives of clients receiving services through the aging
3622	resource center, and any other persons or groups as determined
3623	by the department. The aging resource center, in consultation
3624	with the work group, must develop annual program improvement
3625	plans that shall be submitted to the department for
3626	consideration. The department shall review each annual
3627	improvement plan and make recommendations on how to implement
3628	the components of the plan.
3629	(g) Enhance the existing area agency on aging in each
3630	planning and service area by integrating, either physically or
3631	virtually, the staff and services of the area agency on aging
3632	with the staff of the department's local CARES Medicaid nursing
3633	home preadmission screening unit and a sufficient number of
3634	staff from the Department of Children and Family Services'
3635	Economic Self-Sufficiency Unit necessary to determine the
3636	financial eligibility for all persons age 60 and older residing
3637	within the area served by the aging resource center that are
3638	seeking Medicaid services, Supplemental Security Income, and
3639	food stamps.
3640	(h) Assist clients who request long-term care services in
3641	being evaluated for eligibility for enrollment in the Medicaid
3642	long-term care managed care program as qualified plans become
3643	available in each of the regions pursuant to s. 409.981(2).
3644	(i) Provide choice counseling for the Medicaid long-term
3645	care managed care program by integrating, either physically or
3646	virtually, choice counseling staff and services as qualified
3647	plans become available in each of the regions pursuant to s.
3648	409.981(2). Pursuant to s. 409.984(1), the agency may contract
3649	directly with the aging resource center to provide choice
3650	counseling services or may contract with another vendor if the
3651	aging resource center does not choose to provide such services.
3652	(j) Assist Medicaid recipients enrolled in the Medicaid
3653	long-term care managed care program with informally resolving
3654	grievances with a managed care network and assist Medicaid
3655	recipients in accessing the managed care network's formal
3656	grievance process as qualified plans become available in each of
3657	the regions pursuant to s. 409.981(2).
3658	(4)(6) The department shall select the entities to become
3659	aging resource centers based on each entity's readiness and
3660	ability to perform the duties listed in subsection (3) (5) and
3661	the entity's:
3662	(a) Expertise in the needs of each target population the
3663	center proposes to serve and a thorough knowledge of the
3664	providers that serve these populations.
3665	(b) Strong connections to service providers, volunteer
3666	agencies, and community institutions.
3667	(c) Expertise in information and referral activities.
3668	(d) Knowledge of long-term-care resources, including
3669	resources designed to provide services in the least restrictive
3670	setting.
3671	(e) Financial solvency and stability.
3672	(f) Ability to collect, monitor, and analyze data in a
3673	timely and accurate manner, along with systems that meet the
3674	department's standards.
3675	(g) Commitment to adequate staffing by qualified personnel
3676	to effectively perform all functions.
3677	(h) Ability to meet all performance standards established
3678	by the department.
3679	(5)(7) The aging resource center shall have a governing
3680	body which shall be the same entity described in s. 20.41(7),
3681	and an executive director who may be the same person as
3682	described in s. 20.41(7). The governing body shall annually
3683	evaluate the performance of the executive director.
3684	(6)(8) The aging resource center may not be a provider of
3685	direct services other than choice counseling as qualified plans
3686	become available in each of the regions pursuant to s.
3687	409.981(2), information and referral services, and screening.
3688	(7)(9) The aging resource center must agree to allow the
3689	department to review any financial information the department
3690	determines is necessary for monitoring or reporting purposes,
3691	including financial relationships.
3692	(8)(10) The duties and responsibilities of the community
3693	care for the elderly lead agencies within each area served by an
3694	aging resource center shall be to:
3695	(a) Develop strong community partnerships to maximize the
3696	use of community resources for the purpose of assisting elders
3697	to remain in their community settings for as long as it is
3698	safely possible.
3699	(b) Conduct comprehensive assessments of clients that have
3700	been determined eligible and develop a care plan consistent with
3701	established protocols that ensures that the unique needs of each
3702	client are met.
3703	(9)(11) The services to be administered through the aging
3704	resource center shall include those funded by the following
3705	programs:
3706	(a) Community care for the elderly.
3707	(b) Home care for the elderly.
3708	(c) Contracted services.
3709	(d) Alzheimer's disease initiative.
3710	(e) Aged and disabled adult Medicaid waiver. This
3711	paragraph expires October 1, 2012.
3712	(f) Assisted living for the frail elderly Medicaid waiver.
3713	This paragraph expires October 1, 2012.
3714	(g) Older Americans Act.
3715	(10)(12) The department shall, prior to designation of an
3716	aging resource center, develop by rule operational and quality
3717	assurance standards and outcome measures to ensure that clients
3718	receiving services through all long-term-care programs
3719	administered through an aging resource center are receiving the
3720	appropriate care they require and that contractors and
3721	subcontractors are adhering to the terms of their contracts and
3722	are acting in the best interests of the clients they are
3723	serving, consistent with the intent of the Legislature to reduce
3724	the use of and cost of nursing home care. The department shall
3725	by rule provide operating procedures for aging resource centers,
3726	which shall include:
3727	(a) Minimum standards for financial operation, including
3728	audit procedures.
3729	(b) Procedures for monitoring and sanctioning of service
3730	providers.
3731	(c) Minimum standards for technology utilized by the aging
3732	resource center.
3733	(d) Minimum staff requirements which shall ensure that the
3734	aging resource center employs sufficient quality and quantity of
3735	staff to adequately meet the needs of the elders residing within
3736	the area served by the aging resource center.
3737	(e) Minimum accessibility standards, including hours of
3738	operation.
3739	(f) Minimum oversight standards for the governing body of
3740	the aging resource center to ensure its continuous involvement
3741	in, and accountability for, all matters related to the
3742	development, implementation, staffing, administration, and
3743	operations of the aging resource center.
3744	(g) Minimum education and experience requirements for
3745	executive directors and other executive staff positions of aging
3746	resource centers.
3747	(h) Minimum requirements regarding any executive staff
3748	positions that the aging resource center must employ and minimum
3749	requirements that a candidate must meet in order to be eligible
3750	for appointment to such positions.
3751	(11)(13) In an area in which the department has designated
3752	an area agency on aging as an aging resource center, the
3753	department and the agency shall not make payments for the
3754	services listed in subsection (9) (11) and the Long-Term Care
3755	Community Diversion Project for such persons who were not
3756	screened and enrolled through the aging resource center. The
3757	department shall cease making payments for recipients in
3758	qualified plans as qualified plans become available in each of
3759	the regions pursuant to s. 409.981(2).
3760	(12)(14) Each aging resource center shall enter into a
3761	memorandum of understanding with the department for
3762	collaboration with the CARES unit staff. The memorandum of
3763	understanding shall outline the staff person responsible for
3764	each function and shall provide the staffing levels necessary to
3765	carry out the functions of the aging resource center.
3766	(13)(15) Each aging resource center shall enter into a
3767	memorandum of understanding with the Department of Children and
3768	Family Services for collaboration with the Economic Self-
3769	Sufficiency Unit staff. The memorandum of understanding shall
3770	outline which staff persons are responsible for which functions
3771	and shall provide the staffing levels necessary to carry out the
3772	functions of the aging resource center.
3773	(14) As qualified plans become available in each of the
3774	regions pursuant to s. 409.981(2), if an aging resource center
3775	does not contract with the agency to provide Medicaid long-term
3776	care managed care choice counseling pursuant to s. 409.984(1),
3777	the aging resource center shall enter into a memorandum of
3778	understanding with the agency to coordinate staffing and
3779	collaborate with the choice counseling vendor. The memorandum of
3780	understanding shall identify the staff responsible for each
3781	function and shall provide the staffing levels necessary to
3782	carry out the functions of the aging resource center.
3783	(15)(16) If any of the state activities described in this
3784	section are outsourced, either in part or in whole, the contract
3785	executing the outsourcing shall mandate that the contractor or
3786	its subcontractors shall, either physically or virtually,
3787	execute the provisions of the memorandum of understanding
3788	instead of the state entity whose function the contractor or
3789	subcontractor now performs.
3790	(16)(17) In order to be eligible to begin transitioning to
3791	an aging resource center, an area agency on aging board must
3792	ensure that the area agency on aging which it oversees meets all
3793	of the minimum requirements set by law and in rule.
3794	(18) The department shall monitor the three initial
3795	projects for aging resource centers and report on the progress
3796	of those projects to the Governor, the President of the Senate,
3797	and the Speaker of the House of Representatives by June 30,
3798	2005. The report must include an evaluation of the
3799	implementation process.
3800	(17)(19)(a) Once an aging resource center is operational,
3801	the department, in consultation with the agency, may develop
3802	capitation rates for any of the programs administered through
3803	the aging resource center. Capitation rates for programs shall
3804	be based on the historical cost experience of the state in
3805	providing those same services to the population age 60 or older
3806	residing within each area served by an aging resource center.
3807	Each capitated rate may vary by geographic area as determined by
3808	the department.
3809	(b) The department and the agency may determine for each
3810	area served by an aging resource center whether it is
3811	appropriate, consistent with federal and state laws and
3812	regulations, to develop and pay separate capitated rates for
3813	each program administered through the aging resource center or
3814	to develop and pay capitated rates for service packages which
3815	include more than one program or service administered through
3816	the aging resource center.
3817	(c) Once capitation rates have been developed and
3818	certified as actuarially sound, the department and the agency
3819	may pay service providers the capitated rates for services when
3820	appropriate.
3821	(d) The department, in consultation with the agency, shall
3822	annually reevaluate and recertify the capitation rates,
3823	adjusting forward to account for inflation, programmatic
3824	changes.
3825	(20) The department, in consultation with the agency,
3826	shall submit to the Governor, the President of the Senate, and
3827	the Speaker of the House of Representatives, by December 1,
3828	2006, a report addressing the feasibility of administering the
3829	following services through aging resource centers beginning July
3830	1, 2007:
3831	(a) Medicaid nursing home services.
3832	(b) Medicaid transportation services.
3833	(c) Medicaid hospice care services.
3834	(d) Medicaid intermediate care services.
3835	(e) Medicaid prescribed drug services.
3836	(f) Medicaid assistive care services.
3837	(g) Any other long-term-care program or Medicaid service.
3838	(18)(21) This section shall not be construed to allow an
3839	aging resource center to restrict, manage, or impede the local
3840	fundraising activities of service providers.
3841	Section 18. Subsection (4) of section 641.386, Florida
3842	Statutes, is amended to read:
3843	641.386 Agent licensing and appointment required;
3844	exceptions.-
3845	(4) All agents and health maintenance organizations shall
3846	comply with and be subject to the applicable provisions of ss.
3847	641.309 and 409.912(20)(21), and all companies and entities
3848	appointing agents shall comply with s. 626.451, when marketing
3849	for any health maintenance organization licensed pursuant to
3850	this part, including those organizations under contract with the
3851	Agency for Health Care Administration to provide health care
3852	services to Medicaid recipients or any private entity providing
3853	health care services to Medicaid recipients pursuant to a
3854	prepaid health plan contract with the Agency for Health Care
3855	Administration.
3856	Section 19. Effective October 1, 2012, sections 430.701,
3857	430.702, 430.703, 430.7031, 430.704, 430.705, 430.706, 430.707,
3858	430.708, and 430.709 Florida Statutes, are repealed.
3859	Section 20. Sections 409.9301, 409.942, 409.944, 409.945,
3860	409.946, 409.953, and 409.9531, Florida Statutes, are renumbered
3861	as sections 402.81, 402.82, 402.83, 402.84, 402.85, 402.86, and
3862	402.87, Florida Statutes, respectively.
3863	Section 21. Paragraph (a) of subsection (1) of section
3864	443.111, Florida Statutes, is amended to read:
3865	443.111 Payment of benefits.-
3866	(1) MANNER OF PAYMENT.-Benefits are payable from the fund
3867	in accordance with rules adopted by the Agency for Workforce
3868	Innovation, subject to the following requirements:
3869	(a) Benefits are payable by mail or electronically.
3870	Notwithstanding s. 402.82(4) 409.942(4), The agency may develop
3871	a system for the payment of benefits by electronic funds
3872	transfer, including, but not limited to, debit cards, electronic
3873	payment cards, or any other means of electronic payment that the
3874	agency deems to be commercially viable or cost-effective.
3875	Commodities or services related to the development of such a
3876	system shall be procured by competitive solicitation, unless
3877	they are purchased from a state term contract pursuant to s.
3878	287.056. The agency shall adopt rules necessary to administer
3879	the system.
3880	Section 22. Except as otherwise expressly provided in this
3881	act, this act shall take effect July 1, 2010, if HB 7223 or
3882	similar legislation is adopted in the same legislative session
3883	or an extension thereof and becomes law.

CODING: Words stricken are deletions; words underlined are additions.