Florida Senate - 2015 SB 704
By Senator Simmons
10-00624A-15 2015704__
1 A reviser’s bill to be entitled
2 An act relating to the Florida Statutes; repealing ss.
3 88.7011, 120.745, 163.336, 218.077(5), 220.33(7),
4 253.01(2)(b), 288.106(4)(f), 339.08(1)(n), 381.0407,
5 403.709(1)(f), 409.911(10), 409.91211, 430.04(15),
6 430.502(10)-(12), 443.131(5), 624.351, 624.352, and
7 626.2815(7), F.S., and amending ss. 110.123, 339.135,
8 409.912, 409.9122, 576.061, 828.27, and 1002.32, F.S.,
9 to delete provisions which have become inoperative by
10 noncurrent repeal or expiration and, pursuant to s.
11 11.242(5)(b) and (i), F.S., may be omitted from the
12 2015 Florida Statutes only through a reviser’s bill
13 duly enacted by the Legislature; amending ss.
14 409.91195, 409.91196, 409.962, 636.0145, 641.19,
15 641.225, and 641.386, F.S., to conform cross
16 references; providing an effective date.
17
18 Be It Enacted by the Legislature of the State of Florida:
19
20 Section 1. Section 88.7011, Florida Statutes, is repealed.
21 Reviser’s note.—Repealed to conform to s. 58, ch. 2011-92, Laws
22 of Florida, which repealed s. 88.7011 effective on a date
23 contingent upon the provisions of s. 81, ch. 2011-92.
24 Section 81, ch. 2011-92, provides that “[e]xcept as
25 otherwise expressly provided in this act, this act shall
26 take effect upon the earlier of 90 days following Congress
27 amending 42 U.S.C. s. 666(f) to allow or require states to
28 adopt the 2008 version of the Uniform Interstate Family
29 Support Act, or 90 days following the state obtaining a
30 waiver of its state plan requirement under Title IV-D of
31 the Social Security Act.” Public Law No. 113-183 was signed
32 by the President on September 29, 2014; a portion of that
33 law requires that the 2008 version of the Uniform
34 Interstate Family Support Act is required.
35 Section 2. Paragraph (g) of subsection (3) of section
36 110.123, Florida Statutes, is amended to read:
37 110.123 State group insurance program.—
38 (3) STATE GROUP INSURANCE PROGRAM.—
39 (g) Participation by individuals in the program is
40 available to all state officers, full-time state employees, and
41 part-time state employees and is voluntary. Participation in the
42 program is also available to retired state officers and
43 employees who elect at the time of retirement to continue
44 coverage under the program, but may elect to continue all or
45 only part of the coverage they had at the time of retirement. A
46 surviving spouse may elect to continue coverage only under a
47 state group health insurance plan, a TRICARE supplemental
48 insurance plan, or a health maintenance organization plan.
49 1. Full-time state employees described in subparagraph
50 (2)(c)1. are eligible for health insurance coverage in calendar
51 year 2014 as long as they remain employed by an employer
52 participating in the state group insurance program during the
53 year. This subparagraph expires December 31, 2014.
54 2. Employees paid from other-personal-services (OPS) funds
55 are not eligible for coverage before January 1, 2014.
56 Reviser’s note.—Amended to delete subparagraph (3)(g)1., which
57 expired pursuant to its own terms, effective December 31,
58 2014, and to delete subparagraph (3)(g)2. to repeal a
59 provision that has served its purpose.
60 Section 3. Section 120.745, Florida Statutes, is repealed.
61 Reviser’s note.—The cited section, which relates to legislative
62 review of agency rules in effect on or before November 16,
63 2010, was repealed pursuant to its own terms, effective
64 July 1, 2014.
65 Section 4. Section 163.336, Florida Statutes, is repealed.
66 Reviser’s note.—The cited section, which relates to the coastal
67 resort area redevelopment pilot project, expired pursuant
68 to its own terms, effective December 31, 2014.
69 Section 5. Subsection (5) of section 218.077, Florida
70 Statutes, is repealed.
71 Reviser’s note.—The cited subsection, which relates to the
72 Employer-Sponsored Benefits Study Task Force, was repealed
73 pursuant to its own terms, effective June 30, 2014.
74 Section 6. Subsection (7) of section 220.33, Florida
75 Statutes, is repealed.
76 Reviser’s note.—The cited subsection, which relates to payment
77 of estimated tax due no later than Sunday, June 30, 2013,
78 by June 28, 2013, expired pursuant to its own terms,
79 effective July 1, 2014.
80 Section 7. Paragraph (b) of subsection (2) of section
81 253.01, Florida Statutes, is repealed.
82 Reviser’s note.—The cited paragraph, which relates to transfer
83 of moneys, for the 2013-2014 fiscal year only, from the
84 Internal Improvement Trust Fund to the Save Our Everglades
85 Trust Fund for Everglades restoration pursuant to s.
86 216.181(12), expired pursuant to its own terms, effective
87 July 1, 2014.
88 Section 8. Paragraph (f) of subsection (4) of section
89 288.106, Florida Statutes, is repealed.
90 Reviser’s note.—The cited paragraph, which permits reduction of
91 local financial support requirements of s. 288.106 by one
92 half for a qualified target industry business located in
93 one of a specified list of counties under certain
94 circumstances, expired pursuant to its own terms, effective
95 June 30, 2014.
96 Section 9. Paragraph (n) of subsection (1) of section
97 339.08, Florida Statutes, is repealed.
98 Reviser’s note.—The cited paragraph, which relates to
99 expenditure of funds to pay administrative expenses
100 incurred in accordance with applicable laws by the
101 multicounty transportation authority created under chapter
102 343 where jurisdiction for the authority includes a portion
103 of the State Highway System and the expenses are in
104 furtherance of the provisions of chapter 2012-174, Laws of
105 Florida, to provide a financial analysis of the cost
106 savings to be achieved by the consolidation of transit
107 authorities within the region, expired pursuant to its own
108 terms, effective July 1, 2014.
109 Section 10. Paragraph (a) of subsection (4) of section
110 339.135, Florida Statutes, is amended to read:
111 339.135 Work program; legislative budget request;
112 definitions; preparation, adoption, execution, and amendment.—
113 (4) FUNDING AND DEVELOPING A TENTATIVE WORK PROGRAM.—
114 (a)1. To assure that no district or county is penalized for
115 local efforts to improve the State Highway System, the
116 department shall, for the purpose of developing a tentative work
117 program, allocate funds for new construction to the districts,
118 except for the turnpike enterprise, based on equal parts of
119 population and motor fuel tax collections. Funds for
120 resurfacing, bridge repair and rehabilitation, bridge fender
121 system construction or repair, public transit projects except
122 public transit block grants as provided in s. 341.052, and other
123 programs with quantitative needs assessments shall be allocated
124 based on the results of these assessments. The department may
125 not transfer any funds allocated to a district under this
126 paragraph to any other district except as provided in subsection
127 (7). Funds for public transit block grants shall be allocated to
128 the districts pursuant to s. 341.052. Funds for the intercity
129 bus program provided for under s. 5311(f) of the federal
130 nonurbanized area formula program shall be administered and
131 allocated directly to eligible bus carriers as defined in s.
132 341.031(12) at the state level rather than the district. In
133 order to provide state funding to support the intercity bus
134 program provided for under provisions of the federal 5311(f)
135 program, the department shall allocate an amount equal to the
136 federal share of the 5311(f) program from amounts calculated
137 pursuant to s. 206.46(3).
138 2. Notwithstanding the provisions of subparagraph 1., the
139 department shall allocate at least 50 percent of any new
140 discretionary highway capacity funds to the Florida Strategic
141 Intermodal System created pursuant to s. 339.61. Any remaining
142 new discretionary highway capacity funds shall be allocated to
143 the districts for new construction as provided in subparagraph
144 1. For the purposes of this subparagraph, the term “new
145 discretionary highway capacity funds” means any funds available
146 to the department above the prior year funding level for
147 capacity improvements, which the department has the discretion
148 to allocate to highway projects.
149 3. Notwithstanding subparagraphs 1. and 2. and ss.
150 206.46(3) and 334.044(26), and for fiscal years 2009-2010
151 through 2013-2014 only, the department shall annually allocate
152 up to $15 million of the first proceeds of the increased
153 revenues estimated by the November 2009 Revenue Estimating
154 Conference to be deposited into the State Transportation Trust
155 Fund to provide for the portion of the transfer of funds
156 included in s. 343.58(4)(a)1.a. or 2.a., as applicable. The
157 transfer of funds included in s. 343.58(4) shall not negatively
158 impact projects included in fiscal years 2009-2010 through 2013
159 2014 of the work program as of July 1, 2009, as amended pursuant
160 to subsection (7). This subparagraph expires July 1, 2014.
161 Reviser’s note.—Amended to delete subparagraph (4)(a)3., which
162 expired pursuant to its own terms, effective July 1, 2014.
163 Section 11. Section 381.0407, Florida Statutes, is
164 repealed.
165 Reviser’s note.—The cited section, the Managed Care and Publicly
166 Funded Primary Care Program Coordination Act, was repealed
167 by s. 51, ch. 2012-184, effective October 1, 2014. Since
168 the section was not repealed by a “current session” of the
169 Legislature, it may be omitted from the 2015 Florida
170 Statutes only through a reviser’s bill duly enacted by the
171 Legislature. See s. 11.242(5)(b) and (i).
172 Section 12. Paragraph (f) of subsection (1) of section
173 403.709, Florida Statutes, is repealed.
174 Reviser’s note.—The cited paragraph, which relates to transfer
175 of moneys, for the 2013-2014 fiscal year only, from the
176 Solid Waste Management Trust Fund to the Save Our
177 Everglades Trust Fund for Everglades restoration pursuant
178 to s. 216.181(12), expired pursuant to its own terms,
179 effective July 1, 2014.
180 Section 13. Subsection (10) of section 409.911, Florida
181 Statutes, is repealed.
182 Reviser’s note.—The cited subsection, which relates to the
183 Medicaid Low-Income Pool Council, expired pursuant to its
184 own terms, effective October 1, 2014.
185 Section 14. Section 409.912, Florida Statutes, is amended
186 to read:
187 409.912 Cost-effective purchasing of health care.—The
188 agency shall purchase goods and services for Medicaid recipients
189 in the most cost-effective manner consistent with the delivery
190 of quality medical care. To ensure that medical services are
191 effectively utilized, the agency may, in any case, require a
192 confirmation or second physician’s opinion of the correct
193 diagnosis for purposes of authorizing future services under the
194 Medicaid program. This section does not restrict access to
195 emergency services or poststabilization care services as defined
196 in 42 C.F.R. s. 438.114. Such confirmation or second opinion
197 shall be rendered in a manner approved by the agency. The agency
198 shall maximize the use of prepaid per capita and prepaid
199 aggregate fixed-sum basis services when appropriate and other
200 alternative service delivery and reimbursement methodologies,
201 including competitive bidding pursuant to s. 287.057, designed
202 to facilitate the cost-effective purchase of a case-managed
203 continuum of care. The agency shall also require providers to
204 minimize the exposure of recipients to the need for acute
205 inpatient, custodial, and other institutional care and the
206 inappropriate or unnecessary use of high-cost services. The
207 agency shall contract with a vendor to monitor and evaluate the
208 clinical practice patterns of providers in order to identify
209 trends that are outside the normal practice patterns of a
210 provider’s professional peers or the national guidelines of a
211 provider’s professional association. The vendor must be able to
212 provide information and counseling to a provider whose practice
213 patterns are outside the norms, in consultation with the agency,
214 to improve patient care and reduce inappropriate utilization.
215 The agency may mandate prior authorization, drug therapy
216 management, or disease management participation for certain
217 populations of Medicaid beneficiaries, certain drug classes, or
218 particular drugs to prevent fraud, abuse, overuse, and possible
219 dangerous drug interactions. The Pharmaceutical and Therapeutics
220 Committee shall make recommendations to the agency on drugs for
221 which prior authorization is required. The agency shall inform
222 the Pharmaceutical and Therapeutics Committee of its decisions
223 regarding drugs subject to prior authorization. The agency is
224 authorized to limit the entities it contracts with or enrolls as
225 Medicaid providers by developing a provider network through
226 provider credentialing. The agency may competitively bid single
227 source-provider contracts if procurement of goods or services
228 results in demonstrated cost savings to the state without
229 limiting access to care. The agency may limit its network based
230 on the assessment of beneficiary access to care, provider
231 availability, provider quality standards, time and distance
232 standards for access to care, the cultural competence of the
233 provider network, demographic characteristics of Medicaid
234 beneficiaries, practice and provider-to-beneficiary standards,
235 appointment wait times, beneficiary use of services, provider
236 turnover, provider profiling, provider licensure history,
237 previous program integrity investigations and findings, peer
238 review, provider Medicaid policy and billing compliance records,
239 clinical and medical record audits, and other factors. Providers
240 are not entitled to enrollment in the Medicaid provider network.
241 The agency shall determine instances in which allowing Medicaid
242 beneficiaries to purchase durable medical equipment and other
243 goods is less expensive to the Medicaid program than long-term
244 rental of the equipment or goods. The agency may establish rules
245 to facilitate purchases in lieu of long-term rentals in order to
246 protect against fraud and abuse in the Medicaid program as
247 defined in s. 409.913. The agency may seek federal waivers
248 necessary to administer these policies.
249 (1) The agency shall work with the Department of Children
250 and Families to ensure access of children and families in the
251 child protection system to needed and appropriate mental health
252 and substance abuse services. This subsection expires October 1,
253 2014.
254 (2) The agency may enter into agreements with appropriate
255 agents of other state agencies or of any agency of the Federal
256 Government and accept such duties in respect to social welfare
257 or public aid as may be necessary to implement the provisions of
258 Title XIX of the Social Security Act and ss. 409.901-409.920.
259 This subsection expires October 1, 2016.
260 (3) The agency may contract with health maintenance
261 organizations certified pursuant to part I of chapter 641 for
262 the provision of services to recipients. This subsection expires
263 October 1, 2014.
264 (2)(4) The agency may contract with:
265 (a) An entity that provides no prepaid health care services
266 other than Medicaid services under contract with the agency and
267 which is owned and operated by a county, county health
268 department, or county-owned and operated hospital to provide
269 health care services on a prepaid or fixed-sum basis to
270 recipients, which entity may provide such prepaid services
271 either directly or through arrangements with other providers.
272 Such prepaid health care services entities must be licensed
273 under parts I and III of chapter 641. An entity recognized under
274 this paragraph which demonstrates to the satisfaction of the
275 Office of Insurance Regulation of the Financial Services
276 Commission that it is backed by the full faith and credit of the
277 county in which it is located may be exempted from s. 641.225.
278 This paragraph expires October 1, 2014.
279 (b) An entity that is providing comprehensive behavioral
280 health care services to certain Medicaid recipients through a
281 capitated, prepaid arrangement pursuant to the federal waiver
282 provided for by s. 409.905(5). Such entity must be licensed
283 under chapter 624, chapter 636, or chapter 641, or authorized
284 under paragraph (c) or paragraph (d), and must possess the
285 clinical systems and operational competence to manage risk and
286 provide comprehensive behavioral health care to Medicaid
287 recipients. As used in this paragraph, the term “comprehensive
288 behavioral health care services” means covered mental health and
289 substance abuse treatment services that are available to
290 Medicaid recipients. The secretary of the Department of Children
291 and Families shall approve provisions of procurements related to
292 children in the department’s care or custody before enrolling
293 such children in a prepaid behavioral health plan. Any contract
294 awarded under this paragraph must be competitively procured. In
295 developing the behavioral health care prepaid plan procurement
296 document, the agency shall ensure that the procurement document
297 requires the contractor to develop and implement a plan to
298 ensure compliance with s. 394.4574 related to services provided
299 to residents of licensed assisted living facilities that hold a
300 limited mental health license. Except as provided in
301 subparagraph 5., and except in counties where the Medicaid
302 managed care pilot program is authorized pursuant to s.
303 409.91211, the agency shall seek federal approval to contract
304 with a single entity meeting these requirements to provide
305 comprehensive behavioral health care services to all Medicaid
306 recipients not enrolled in a Medicaid managed care plan
307 authorized under s. 409.91211, a provider service network
308 authorized under paragraph (d), or a Medicaid health maintenance
309 organization in an AHCA area. In an AHCA area where the Medicaid
310 managed care pilot program is authorized pursuant to s.
311 409.91211 in one or more counties, the agency may procure a
312 contract with a single entity to serve the remaining counties as
313 an AHCA area or the remaining counties may be included with an
314 adjacent AHCA area and are subject to this paragraph. Each
315 entity must offer a sufficient choice of providers in its
316 network to ensure recipient access to care and the opportunity
317 to select a provider with whom they are satisfied. The network
318 shall include all public mental health hospitals. To ensure
319 unimpaired access to behavioral health care services by Medicaid
320 recipients, all contracts issued pursuant to this paragraph must
321 require 80 percent of the capitation paid to the managed care
322 plan, including health maintenance organizations and capitated
323 provider service networks, to be expended for the provision of
324 behavioral health care services. If the managed care plan
325 expends less than 80 percent of the capitation paid for the
326 provision of behavioral health care services, the difference
327 shall be returned to the agency. The agency shall provide the
328 plan with a certification letter indicating the amount of
329 capitation paid during each calendar year for behavioral health
330 care services pursuant to this section. The agency may reimburse
331 for substance abuse treatment services on a fee-for-service
332 basis until the agency finds that adequate funds are available
333 for capitated, prepaid arrangements.
334 1. The agency shall modify the contracts with the entities
335 providing comprehensive inpatient and outpatient mental health
336 care services to Medicaid recipients in Hillsborough, Highlands,
337 Hardee, Manatee, and Polk Counties, to include substance abuse
338 treatment services.
339 2. Except as provided in subparagraph 5., the agency and
340 the Department of Children and Families shall contract with
341 managed care entities in each AHCA area except area 6 or arrange
342 to provide comprehensive inpatient and outpatient mental health
343 and substance abuse services through capitated prepaid
344 arrangements to all Medicaid recipients who are eligible to
345 participate in such plans under federal law and regulation. In
346 AHCA areas where eligible individuals number less than 150,000,
347 the agency shall contract with a single managed care plan to
348 provide comprehensive behavioral health services to all
349 recipients who are not enrolled in a Medicaid health maintenance
350 organization, a provider service network authorized under
351 paragraph (d), or a Medicaid capitated managed care plan
352 authorized under s. 409.91211. The agency may contract with more
353 than one comprehensive behavioral health provider to provide
354 care to recipients who are not enrolled in a Medicaid capitated
355 managed care plan authorized under s. 409.91211, a provider
356 service network authorized under paragraph (d), or a Medicaid
357 health maintenance organization in AHCA areas where the eligible
358 population exceeds 150,000. In an AHCA area where the Medicaid
359 managed care pilot program is authorized pursuant to s.
360 409.91211 in one or more counties, the agency may procure a
361 contract with a single entity to serve the remaining counties as
362 an AHCA area or the remaining counties may be included with an
363 adjacent AHCA area and shall be subject to this paragraph.
364 Contracts for comprehensive behavioral health providers awarded
365 pursuant to this section shall be competitively procured. Both
366 for-profit and not-for-profit corporations are eligible to
367 compete. Managed care plans contracting with the agency under
368 subsection (3) or paragraph (d) shall provide and receive
369 payment for the same comprehensive behavioral health benefits as
370 provided in AHCA rules, including handbooks incorporated by
371 reference. In AHCA area 11, the agency shall contract with at
372 least two comprehensive behavioral health care providers to
373 provide behavioral health care to recipients in that area who
374 are enrolled in, or assigned to, the MediPass program. One of
375 the behavioral health care contracts must be with the existing
376 provider service network pilot project, as described in
377 paragraph (d), for the purpose of demonstrating the cost
378 effectiveness of the provision of quality mental health services
379 through a public hospital-operated managed care model. Payment
380 shall be at an agreed-upon capitated rate to ensure cost
381 savings. Of the recipients in area 11 who are assigned to
382 MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those
383 MediPass-enrolled recipients shall be assigned to the existing
384 provider service network in area 11 for their behavioral care.
385 3. Children residing in a statewide inpatient psychiatric
386 program, or in a Department of Juvenile Justice or a Department
387 of Children and Families residential program approved as a
388 Medicaid behavioral health overlay services provider may not be
389 included in a behavioral health care prepaid health plan or any
390 other Medicaid managed care plan pursuant to this paragraph.
391 4. Traditional community mental health providers under
392 contract with the Department of Children and Families pursuant
393 to part IV of chapter 394, child welfare providers under
394 contract with the Department of Children and Families in areas 1
395 and 6, and inpatient mental health providers licensed pursuant
396 to chapter 395 must be offered an opportunity to accept or
397 decline a contract to participate in any provider network for
398 prepaid behavioral health services.
399 5. All Medicaid-eligible children, except children in area
400 1 and children in Highlands County, Hardee County, Polk County,
401 or Manatee County of area 6, which are open for child welfare
402 services in the statewide automated child welfare information
403 system, shall receive their behavioral health care services
404 through a specialty prepaid plan operated by community-based
405 lead agencies through a single agency or formal agreements among
406 several agencies. The agency shall work with the specialty plan
407 to develop clinically effective, evidence-based alternatives as
408 a downward substitution for the statewide inpatient psychiatric
409 program and similar residential care and institutional services.
410 The specialty prepaid plan must result in savings to the state
411 comparable to savings achieved in other Medicaid managed care
412 and prepaid programs. Such plan must provide mechanisms to
413 maximize state and local revenues. The specialty prepaid plan
414 shall be developed by the agency and the Department of Children
415 and Families. The agency may seek federal waivers to implement
416 this initiative. Medicaid-eligible children whose cases are open
417 for child welfare services in the statewide automated child
418 welfare information system and who reside in AHCA area 10 shall
419 be enrolled in a capitated provider service network or other
420 capitated managed care plan, which, in coordination with
421 available community-based care providers specified in s.
422 409.987, shall provide sufficient medical, developmental, and
423 behavioral health services to meet the needs of these children.
424
425 Effective July 1, 2012, in order to ensure continuity of care,
426 the agency is authorized to extend or modify current contracts
427 based on current service areas or on a regional basis, as
428 determined appropriate by the agency, with comprehensive
429 behavioral health care providers as described in this paragraph
430 during the period prior to its expiration. This paragraph
431 expires October 1, 2014.
432 (c) A federally qualified health center or an entity owned
433 by one or more federally qualified health centers or an entity
434 owned by other migrant and community health centers receiving
435 non-Medicaid financial support from the Federal Government to
436 provide health care services on a prepaid or fixed-sum basis to
437 recipients. A federally qualified health center or an entity
438 that is owned by one or more federally qualified health centers
439 and is reimbursed by the agency on a prepaid basis is exempt
440 from parts I and III of chapter 641, but must comply with the
441 solvency requirements in s. 641.2261(2) and meet the appropriate
442 requirements governing financial reserve, quality assurance, and
443 patients’ rights established by the agency. This paragraph
444 expires October 1, 2014.
445 (d)1. a provider service network, which may be reimbursed
446 on a fee-for-service or prepaid basis. Prepaid provider service
447 networks shall receive per-member, per-month payments. A
448 provider service network that does not choose to be a prepaid
449 plan shall receive fee-for-service rates with a shared savings
450 settlement. The fee-for-service option shall be available to a
451 provider service network only for the first 2 years of the
452 plan’s operation or until the contract year beginning September
453 1, 2014, whichever is later. The agency shall annually conduct
454 cost reconciliations to determine the amount of cost savings
455 achieved by fee-for-service provider service networks for the
456 dates of service in the period being reconciled. Only payments
457 for covered services for dates of service within the
458 reconciliation period and paid within 6 months after the last
459 date of service in the reconciliation period shall be included.
460 The agency shall perform the necessary adjustments for the
461 inclusion of claims incurred but not reported within the
462 reconciliation for claims that could be received and paid by the
463 agency after the 6-month claims processing time lag. The agency
464 shall provide the results of the reconciliations to the fee-for
465 service provider service networks within 45 days after the end
466 of the reconciliation period. The fee-for-service provider
467 service networks shall review and provide written comments or a
468 letter of concurrence to the agency within 45 days after receipt
469 of the reconciliation results. This reconciliation shall be
470 considered final.
471 (a)2. A provider service network which is reimbursed by the
472 agency on a prepaid basis shall be exempt from parts I and III
473 of chapter 641, but must comply with the solvency requirements
474 in s. 641.2261(2) and meet appropriate financial reserve,
475 quality assurance, and patient rights requirements as
476 established by the agency.
477 3. Medicaid recipients assigned to a provider service
478 network shall be chosen equally from those who would otherwise
479 have been assigned to prepaid plans and MediPass. The agency is
480 authorized to seek federal Medicaid waivers as necessary to
481 implement the provisions of this section. This subparagraph
482 expires October 1, 2014.
483 (b)4. A provider service network is a network established
484 or organized and operated by a health care provider, or group of
485 affiliated health care providers, including minority physician
486 networks and emergency room diversion programs that meet the
487 requirements of s. 409.91211, which provides a substantial
488 proportion of the health care items and services under a
489 contract directly through the provider or affiliated group of
490 providers and may make arrangements with physicians or other
491 health care professionals, health care institutions, or any
492 combination of such individuals or institutions to assume all or
493 part of the financial risk on a prospective basis for the
494 provision of basic health services by the physicians, by other
495 health professionals, or through the institutions. The health
496 care providers must have a controlling interest in the governing
497 body of the provider service network organization.
498 (e) An entity that provides only comprehensive behavioral
499 health care services to certain Medicaid recipients through an
500 administrative services organization agreement. Such an entity
501 must possess the clinical systems and operational competence to
502 provide comprehensive health care to Medicaid recipients. As
503 used in this paragraph, the term “comprehensive behavioral
504 health care services” means covered mental health and substance
505 abuse treatment services that are available to Medicaid
506 recipients. Any contract awarded under this paragraph must be
507 competitively procured. The agency must ensure that Medicaid
508 recipients have available the choice of at least two managed
509 care plans for their behavioral health care services. This
510 paragraph expires October 1, 2014.
511 (f) An entity authorized in s. 430.205 to contract with the
512 agency and the Department of Elderly Affairs to provide health
513 care and social services on a prepaid or fixed-sum basis to
514 elderly recipients. Such prepaid health care services entities
515 are exempt from the provisions of part I of chapter 641 for the
516 first 3 years of operation. An entity recognized under this
517 paragraph that demonstrates to the satisfaction of the Office of
518 Insurance Regulation that it is backed by the full faith and
519 credit of one or more counties in which it operates may be
520 exempted from s. 641.225. This paragraph expires October 1,
521 2013.
522 (g) A Children’s Medical Services Network, as defined in s.
523 391.021. This paragraph expires October 1, 2014.
524 (5) The agency may contract with any public or private
525 entity otherwise authorized by this section on a prepaid or
526 fixed-sum basis for the provision of health care services to
527 recipients. An entity may provide prepaid services to
528 recipients, either directly or through arrangements with other
529 entities, if each entity involved in providing services:
530 (a) Is organized primarily for the purpose of providing
531 health care or other services of the type regularly offered to
532 Medicaid recipients;
533 (b) Ensures that services meet the standards set by the
534 agency for quality, appropriateness, and timeliness;
535 (c) Makes provisions satisfactory to the agency for
536 insolvency protection and ensures that neither enrolled Medicaid
537 recipients nor the agency will be liable for the debts of the
538 entity;
539 (d) Submits to the agency, if a private entity, a financial
540 plan that the agency finds to be fiscally sound and that
541 provides for working capital in the form of cash or equivalent
542 liquid assets excluding revenues from Medicaid premium payments
543 equal to at least the first 3 months of operating expenses or
544 $200,000, whichever is greater;
545 (e) Furnishes evidence satisfactory to the agency of
546 adequate liability insurance coverage or an adequate plan of
547 self-insurance to respond to claims for injuries arising out of
548 the furnishing of health care;
549 (f) Provides, through contract or otherwise, for periodic
550 review of its medical facilities and services, as required by
551 the agency; and
552 (g) Provides organizational, operational, financial, and
553 other information required by the agency.
554
555 This subsection expires October 1, 2014.
556 (6) The agency may contract on a prepaid or fixed-sum basis
557 with any health insurer that:
558 (a) Pays for health care services provided to enrolled
559 Medicaid recipients in exchange for a premium payment paid by
560 the agency;
561 (b) Assumes the underwriting risk; and
562 (c) Is organized and licensed under applicable provisions
563 of the Florida Insurance Code and is currently in good standing
564 with the Office of Insurance Regulation.
565
566 This subsection expires October 1, 2014.
567 (7) The agency may contract on a prepaid or fixed-sum basis
568 with an exclusive provider organization to provide health care
569 services to Medicaid recipients provided that the exclusive
570 provider organization meets applicable managed care plan
571 requirements in this section, ss. 409.9122, 409.9123, 409.9128,
572 and 627.6472, and other applicable provisions of law. This
573 subsection expires October 1, 2014.
574 (8) The Agency for Health Care Administration may provide
575 cost-effective purchasing of chiropractic services on a fee-for
576 service basis to Medicaid recipients through arrangements with a
577 statewide chiropractic preferred provider organization
578 incorporated in this state as a not-for-profit corporation. The
579 agency shall ensure that the benefit limits and prior
580 authorization requirements in the current Medicaid program shall
581 apply to the services provided by the chiropractic preferred
582 provider organization. This subsection expires October 1, 2014.
583 (9) The agency shall not contract on a prepaid or fixed-sum
584 basis for Medicaid services with an entity which knows or
585 reasonably should know that any officer, director, agent,
586 managing employee, or owner of stock or beneficial interest in
587 excess of 5 percent common or preferred stock, or the entity
588 itself, has been found guilty of, regardless of adjudication, or
589 entered a plea of nolo contendere, or guilty, to:
590 (a) Fraud;
591 (b) Violation of federal or state antitrust statutes,
592 including those proscribing price fixing between competitors and
593 the allocation of customers among competitors;
594 (c) Commission of a felony involving embezzlement, theft,
595 forgery, income tax evasion, bribery, falsification or
596 destruction of records, making false statements, receiving
597 stolen property, making false claims, or obstruction of justice;
598 or
599 (d) Any crime in any jurisdiction which directly relates to
600 the provision of health services on a prepaid or fixed-sum
601 basis.
602
603 This subsection expires October 1, 2014.
604 (3)(10) The agency, after notifying the Legislature, may
605 apply for waivers of applicable federal laws and regulations as
606 necessary to implement more appropriate systems of health care
607 for Medicaid recipients and reduce the cost of the Medicaid
608 program to the state and federal governments and shall implement
609 such programs, after legislative approval, within a reasonable
610 period of time after federal approval. These programs must be
611 designed primarily to reduce the need for inpatient care,
612 custodial care and other long-term or institutional care, and
613 other high-cost services. Prior to seeking legislative approval
614 of such a waiver as authorized by this subsection, the agency
615 shall provide notice and an opportunity for public comment.
616 Notice shall be provided to all persons who have made requests
617 of the agency for advance notice and shall be published in the
618 Florida Administrative Register not less than 28 days prior to
619 the intended action. This subsection expires October 1, 2016.
620 (11) The agency shall establish a postpayment utilization
621 control program designed to identify recipients who may
622 inappropriately overuse or underuse Medicaid services and shall
623 provide methods to correct such misuse. This subsection expires
624 October 1, 2014.
625 (12) The agency shall develop and provide coordinated
626 systems of care for Medicaid recipients and may contract with
627 public or private entities to develop and administer such
628 systems of care among public and private health care providers
629 in a given geographic area. This subsection expires October 1,
630 2014.
631 (13) The agency shall operate or contract for the operation
632 of utilization management and incentive systems designed to
633 encourage cost-effective use of services and to eliminate
634 services that are medically unnecessary. The agency shall track
635 Medicaid provider prescription and billing patterns and evaluate
636 them against Medicaid medical necessity criteria and coverage
637 and limitation guidelines adopted by rule. Medical necessity
638 determination requires that service be consistent with symptoms
639 or confirmed diagnosis of illness or injury under treatment and
640 not in excess of the patient’s needs. The agency shall conduct
641 reviews of provider exceptions to peer group norms and shall,
642 using statistical methodologies, provider profiling, and
643 analysis of billing patterns, detect and investigate abnormal or
644 unusual increases in billing or payment of claims for Medicaid
645 services and medically unnecessary provision of services.
646 Providers that demonstrate a pattern of submitting claims for
647 medically unnecessary services shall be referred to the Medicaid
648 program integrity unit for investigation. In its annual report,
649 required in s. 409.913, the agency shall report on its efforts
650 to control overutilization as described in this subsection. This
651 subsection expires October 1, 2014.
652 (14)(a) The agency shall operate the Comprehensive
653 Assessment and Review for Long-Term Care Services (CARES)
654 nursing facility preadmission screening program to ensure that
655 Medicaid payment for nursing facility care is made only for
656 individuals whose conditions require such care and to ensure
657 that long-term care services are provided in the setting most
658 appropriate to the needs of the person and in the most
659 economical manner possible. The CARES program shall also ensure
660 that individuals participating in Medicaid home and community
661 based waiver programs meet criteria for those programs,
662 consistent with approved federal waivers.
663 (b) The agency shall operate the CARES program through an
664 interagency agreement with the Department of Elderly Affairs.
665 The agency, in consultation with the Department of Elderly
666 Affairs, may contract for any function or activity of the CARES
667 program, including any function or activity required by 42
668 C.F.R. s. 483.20, relating to preadmission screening and
669 resident review.
670 (c) Prior to making payment for nursing facility services
671 for a Medicaid recipient, the agency must verify that the
672 nursing facility preadmission screening program has determined
673 that the individual requires nursing facility care and that the
674 individual cannot be safely served in community-based programs.
675 The nursing facility preadmission screening program shall refer
676 a Medicaid recipient to a community-based program if the
677 individual could be safely served at a lower cost and the
678 recipient chooses to participate in such program. For
679 individuals whose nursing home stay is initially funded by
680 Medicare and Medicare coverage is being terminated for lack of
681 progress towards rehabilitation, CARES staff shall consult with
682 the person making the determination of progress toward
683 rehabilitation to ensure that the recipient is not being
684 inappropriately disqualified from Medicare coverage. If, in
685 their professional judgment, CARES staff believes that a
686 Medicare beneficiary is still making progress toward
687 rehabilitation, they may assist the Medicare beneficiary with an
688 appeal of the disqualification from Medicare coverage. The use
689 of CARES teams to review Medicare denials for coverage under
690 this section is authorized only if it is determined that such
691 reviews qualify for federal matching funds through Medicaid. The
692 agency shall seek or amend federal waivers as necessary to
693 implement this section.
694 (d) For the purpose of initiating immediate prescreening
695 and diversion assistance for individuals residing in nursing
696 homes and in order to make families aware of alternative long
697 term care resources so that they may choose a more cost
698 effective setting for long-term placement, CARES staff shall
699 conduct an assessment and review of a sample of individuals
700 whose nursing home stay is expected to exceed 20 days,
701 regardless of the initial funding source for the nursing home
702 placement. CARES staff shall provide counseling and referral
703 services to these individuals regarding choosing appropriate
704 long-term care alternatives. This paragraph does not apply to
705 continuing care facilities licensed under chapter 651 or to
706 retirement communities that provide a combination of nursing
707 home, independent living, and other long-term care services.
708 (e) By January 15 of each year, the agency shall submit a
709 report to the Legislature describing the operations of the CARES
710 program. The report must describe:
711 1. Rate of diversion to community alternative programs;
712 2. CARES program staffing needs to achieve additional
713 diversions;
714 3. Reasons the program is unable to place individuals in
715 less restrictive settings when such individuals desired such
716 services and could have been served in such settings;
717 4. Barriers to appropriate placement, including barriers
718 due to policies or operations of other agencies or state-funded
719 programs; and
720 5. Statutory changes necessary to ensure that individuals
721 in need of long-term care services receive care in the least
722 restrictive environment.
723 (f) The Department of Elderly Affairs shall track
724 individuals over time who are assessed under the CARES program
725 and who are diverted from nursing home placement. By January 15
726 of each year, the department shall submit to the Legislature a
727 longitudinal study of the individuals who are diverted from
728 nursing home placement. The study must include:
729 1. The demographic characteristics of the individuals
730 assessed and diverted from nursing home placement, including,
731 but not limited to, age, race, gender, frailty, caregiver
732 status, living arrangements, and geographic location;
733 2. A summary of community services provided to individuals
734 for 1 year after assessment and diversion;
735 3. A summary of inpatient hospital admissions for
736 individuals who have been diverted; and
737 4. A summary of the length of time between diversion and
738 subsequent entry into a nursing home or death.
739
740 This subsection expires October 1, 2013.
741 (15)(a) The agency shall identify health care utilization
742 and price patterns within the Medicaid program which are not
743 cost-effective or medically appropriate and assess the
744 effectiveness of new or alternate methods of providing and
745 monitoring service, and may implement such methods as it
746 considers appropriate. Such methods may include disease
747 management initiatives, an integrated and systematic approach
748 for managing the health care needs of recipients who are at risk
749 of or diagnosed with a specific disease by using best practices,
750 prevention strategies, clinical-practice improvement, clinical
751 interventions and protocols, outcomes research, information
752 technology, and other tools and resources to reduce overall
753 costs and improve measurable outcomes.
754 (b) The responsibility of the agency under this subsection
755 includes the development of capabilities to identify actual and
756 optimal practice patterns; patient and provider educational
757 initiatives; methods for determining patient compliance with
758 prescribed treatments; fraud, waste, and abuse prevention and
759 detection programs; and beneficiary case management programs.
760 1. The practice pattern identification program shall
761 evaluate practitioner prescribing patterns based on national and
762 regional practice guidelines, comparing practitioners to their
763 peer groups. The agency and its Drug Utilization Review Board
764 shall consult with the Department of Health and a panel of
765 practicing health care professionals consisting of the
766 following: the Speaker of the House of Representatives and the
767 President of the Senate shall each appoint three physicians
768 licensed under chapter 458 or chapter 459, and the Governor
769 shall appoint two pharmacists licensed under chapter 465 and one
770 dentist licensed under chapter 466 who is an oral surgeon. Terms
771 of the panel members shall expire at the discretion of the
772 appointing official. The advisory panel shall be responsible for
773 evaluating treatment guidelines and recommending ways to
774 incorporate their use in the practice pattern identification
775 program. Practitioners who are prescribing inappropriately or
776 inefficiently, as determined by the agency, may have their
777 prescribing of certain drugs subject to prior authorization or
778 may be terminated from all participation in the Medicaid
779 program.
780 2. The agency shall also develop educational interventions
781 designed to promote the proper use of medications by providers
782 and beneficiaries.
783 3. The agency shall implement a pharmacy fraud, waste, and
784 abuse initiative that may include a surety bond or letter of
785 credit requirement for participating pharmacies, enhanced
786 provider auditing practices, the use of additional fraud and
787 abuse software, recipient management programs for beneficiaries
788 inappropriately using their benefits, and other steps that
789 eliminate provider and recipient fraud, waste, and abuse. The
790 initiative shall address enforcement efforts to reduce the
791 number and use of counterfeit prescriptions.
792 4. The agency may contract with an entity in the state to
793 provide Medicaid providers with electronic access to Medicaid
794 prescription refill data and information relating to the
795 Medicaid preferred drug list. The initiative shall be designed
796 to enhance the agency’s efforts to reduce fraud, abuse, and
797 errors in the prescription drug benefit program and to otherwise
798 further the intent of this paragraph.
799 5. The agency shall contract with an entity to design a
800 database of clinical utilization information or electronic
801 medical records for Medicaid providers. The database must be
802 web-based and allow providers to review on a real-time basis the
803 utilization of Medicaid services, including, but not limited to,
804 physician office visits, inpatient and outpatient
805 hospitalizations, laboratory and pathology services,
806 radiological and other imaging services, dental care, and
807 patterns of dispensing prescription drugs in order to coordinate
808 care and identify potential fraud and abuse.
809 6. The agency may apply for any federal waivers needed to
810 administer this paragraph.
811
812 This subsection expires October 1, 2014.
813 (16) An entity contracting on a prepaid or fixed-sum basis
814 shall meet the surplus requirements of s. 641.225. If an
815 entity’s surplus falls below an amount equal to the surplus
816 requirements of s. 641.225, the agency shall prohibit the entity
817 from engaging in marketing and preenrollment activities, shall
818 cease to process new enrollments, and may not renew the entity’s
819 contract until the required balance is achieved. The
820 requirements of this subsection do not apply:
821 (a) Where a public entity agrees to fund any deficit
822 incurred by the contracting entity; or
823 (b) Where the entity’s performance and obligations are
824 guaranteed in writing by a guaranteeing organization which:
825 1. Has been in operation for at least 5 years and has
826 assets in excess of $50 million; or
827 2. Submits a written guarantee acceptable to the agency
828 which is irrevocable during the term of the contracting entity’s
829 contract with the agency and, upon termination of the contract,
830 until the agency receives proof of satisfaction of all
831 outstanding obligations incurred under the contract.
832
833 This subsection expires October 1, 2014.
834 (4)(17)(a) The agency may require an entity contracting on
835 a prepaid or fixed-sum basis to establish a restricted
836 insolvency protection account with a federally guaranteed
837 financial institution licensed to do business in this state. The
838 entity shall deposit into that account 5 percent of the
839 capitation payments made by the agency each month until a
840 maximum total of 2 percent of the total current contract amount
841 is reached. The restricted insolvency protection account may be
842 drawn upon with the authorized signatures of two persons
843 designated by the entity and two representatives of the agency.
844 If the agency finds that the entity is insolvent, the agency may
845 draw upon the account solely with the two authorized signatures
846 of representatives of the agency, and the funds may be disbursed
847 to meet financial obligations incurred by the entity under the
848 prepaid contract. If the contract is terminated, expired, or not
849 continued, the account balance must be released by the agency to
850 the entity upon receipt of proof of satisfaction of all
851 outstanding obligations incurred under this contract.
852 (b) The agency may waive the insolvency protection account
853 requirement in writing when evidence is on file with the agency
854 of adequate insolvency insurance and reinsurance that will
855 protect enrollees if the entity becomes unable to meet its
856 obligations.
857 (18) An entity that contracts with the agency on a prepaid
858 or fixed-sum basis for the provision of Medicaid services shall
859 reimburse any hospital or physician that is outside the entity’s
860 authorized geographic service area as specified in its contract
861 with the agency, and that provides services authorized by the
862 entity to its members, at a rate negotiated with the hospital or
863 physician for the provision of services or according to the
864 lesser of the following:
865 (a) The usual and customary charges made to the general
866 public by the hospital or physician; or
867 (b) The Florida Medicaid reimbursement rate established for
868 the hospital or physician.
869
870 This subsection expires October 1, 2014.
871 (19) When a merger or acquisition of a Medicaid prepaid
872 contractor has been approved by the Office of Insurance
873 Regulation pursuant to s. 628.4615, the agency shall approve the
874 assignment or transfer of the appropriate Medicaid prepaid
875 contract upon request of the surviving entity of the merger or
876 acquisition if the contractor and the other entity have been in
877 good standing with the agency for the most recent 12-month
878 period, unless the agency determines that the assignment or
879 transfer would be detrimental to the Medicaid recipients or the
880 Medicaid program. To be in good standing, an entity must not
881 have failed accreditation or committed any material violation of
882 the requirements of s. 641.52 and must meet the Medicaid
883 contract requirements. For purposes of this section, a merger or
884 acquisition means a change in controlling interest of an entity,
885 including an asset or stock purchase. This subsection expires
886 October 1, 2014.
887 (5)(20) Any entity contracting with the agency pursuant to
888 this section to provide health care services to Medicaid
889 recipients is prohibited from engaging in any of the following
890 practices or activities:
891 (a) Practices that are discriminatory, including, but not
892 limited to, attempts to discourage participation on the basis of
893 actual or perceived health status.
894 (b) Activities that could mislead or confuse recipients, or
895 misrepresent the organization, its marketing representatives, or
896 the agency. Violations of this paragraph include, but are not
897 limited to:
898 1. False or misleading claims that marketing
899 representatives are employees or representatives of the state or
900 county, or of anyone other than the entity or the organization
901 by whom they are reimbursed.
902 2. False or misleading claims that the entity is
903 recommended or endorsed by any state or county agency, or by any
904 other organization which has not certified its endorsement in
905 writing to the entity.
906 3. False or misleading claims that the state or county
907 recommends that a Medicaid recipient enroll with an entity.
908 4. Claims that a Medicaid recipient will lose benefits
909 under the Medicaid program, or any other health or welfare
910 benefits to which the recipient is legally entitled, if the
911 recipient does not enroll with the entity.
912 (c) Granting or offering of any monetary or other valuable
913 consideration for enrollment, except as authorized by subsection
914 (23).
915 (d) Door-to-door solicitation of recipients who have not
916 contacted the entity or who have not invited the entity to make
917 a presentation.
918 (e) Solicitation of Medicaid recipients by marketing
919 representatives stationed in state offices unless approved and
920 supervised by the agency or its agent and approved by the
921 affected state agency when solicitation occurs in an office of
922 the state agency. The agency shall ensure that marketing
923 representatives stationed in state offices shall market their
924 managed care plans to Medicaid recipients only in designated
925 areas and in such a way as to not interfere with the recipients’
926 activities in the state office.
927 (f) Enrollment of Medicaid recipients.
928 (6)(21) The agency may impose a fine for a violation of
929 this section or the contract with the agency by a person or
930 entity that is under contract with the agency. With respect to
931 any nonwillful violation, such fine shall not exceed $2,500 per
932 violation. In no event shall such fine exceed an aggregate
933 amount of $10,000 for all nonwillful violations arising out of
934 the same action. With respect to any knowing and willful
935 violation of this section or the contract with the agency, the
936 agency may impose a fine upon the entity in an amount not to
937 exceed $20,000 for each such violation. In no event shall such
938 fine exceed an aggregate amount of $100,000 for all knowing and
939 willful violations arising out of the same action.
940 (22) A health maintenance organization or a person or
941 entity exempt from chapter 641 that is under contract with the
942 agency for the provision of health care services to Medicaid
943 recipients may not use or distribute marketing materials used to
944 solicit Medicaid recipients, unless such materials have been
945 approved by the agency. The provisions of this subsection do not
946 apply to general advertising and marketing materials used by a
947 health maintenance organization to solicit both non-Medicaid
948 subscribers and Medicaid recipients. This subsection expires
949 October 1, 2014.
950 (23) Upon approval by the agency, health maintenance
951 organizations and persons or entities exempt from chapter 641
952 that are under contract with the agency for the provision of
953 health care services to Medicaid recipients may be permitted
954 within the capitation rate to provide additional health benefits
955 that the agency has found are of high quality, are practicably
956 available, provide reasonable value to the recipient, and are
957 provided at no additional cost to the state. This subsection
958 expires October 1, 2014.
959 (24) The agency shall utilize the statewide health
960 maintenance organization complaint hotline for the purpose of
961 investigating and resolving Medicaid and prepaid health plan
962 complaints, maintaining a record of complaints and confirmed
963 problems, and receiving disenrollment requests made by
964 recipients. This subsection expires October 1, 2014.
965 (25) The agency shall require the publication of the health
966 maintenance organization’s and the prepaid health plan’s
967 consumer services telephone numbers and the “800” telephone
968 number of the statewide health maintenance organization
969 complaint hotline on each Medicaid identification card issued by
970 a health maintenance organization or prepaid health plan
971 contracting with the agency to serve Medicaid recipients and on
972 each subscriber handbook issued to a Medicaid recipient. This
973 subsection expires October 1, 2014.
974 (7)(26) The agency shall establish a health care quality
975 improvement system for those entities contracting with the
976 agency pursuant to this section, incorporating all the standards
977 and guidelines developed by the Centers for Medicare and
978 Medicaid Services Bureau of the Health Care Financing
979 Administration as a part of the quality assurance reform
980 initiative. The system shall include, but need not be limited
981 to, the following:
982 (a) Guidelines for internal quality assurance programs,
983 including standards for:
984 1. Written quality assurance program descriptions.
985 2. Responsibilities of the governing body for monitoring,
986 evaluating, and making improvements to care.
987 3. An active quality assurance committee.
988 4. Quality assurance program supervision.
989 5. Requiring the program to have adequate resources to
990 effectively carry out its specified activities.
991 6. Provider participation in the quality assurance program.
992 7. Delegation of quality assurance program activities.
993 8. Credentialing and recredentialing.
994 9. Enrollee rights and responsibilities.
995 10. Availability and accessibility to services and care.
996 11. Ambulatory care facilities.
997 12. Accessibility and availability of medical records, as
998 well as proper recordkeeping and process for record review.
999 13. Utilization review.
1000 14. A continuity of care system.
1001 15. Quality assurance program documentation.
1002 16. Coordination of quality assurance activity with other
1003 management activity.
1004 17. Delivering care to pregnant women and infants; to
1005 elderly and disabled recipients, especially those who are at
1006 risk of institutional placement; to persons with developmental
1007 disabilities; and to adults who have chronic, high-cost medical
1008 conditions.
1009 (b) Guidelines which require the entities to conduct
1010 quality-of-care studies which:
1011 1. Target specific conditions and specific health service
1012 delivery issues for focused monitoring and evaluation.
1013 2. Use clinical care standards or practice guidelines to
1014 objectively evaluate the care the entity delivers or fails to
1015 deliver for the targeted clinical conditions and health services
1016 delivery issues.
1017 3. Use quality indicators derived from the clinical care
1018 standards or practice guidelines to screen and monitor care and
1019 services delivered.
1020 (c) Guidelines for external quality review of each
1021 contractor which require: focused studies of patterns of care;
1022 individual care review in specific situations; and followup
1023 activities on previous pattern-of-care study findings and
1024 individual-care-review findings. In designing the external
1025 quality review function and determining how it is to operate as
1026 part of the state’s overall quality improvement system, the
1027 agency shall construct its external quality review organization
1028 and entity contracts to address each of the following:
1029 1. Delineating the role of the external quality review
1030 organization.
1031 2. Length of the external quality review organization
1032 contract with the state.
1033 3. Participation of the contracting entities in designing
1034 external quality review organization review activities.
1035 4. Potential variation in the type of clinical conditions
1036 and health services delivery issues to be studied at each plan.
1037 5. Determining the number of focused pattern-of-care
1038 studies to be conducted for each plan.
1039 6. Methods for implementing focused studies.
1040 7. Individual care review.
1041 8. Followup activities.
1042
1043 This subsection expires October 1, 2016.
1044 (27) In order to ensure that children receive health care
1045 services for which an entity has already been compensated, an
1046 entity contracting with the agency pursuant to this section
1047 shall achieve an annual Early and Periodic Screening, Diagnosis,
1048 and Treatment (EPSDT) Service screening rate of at least 60
1049 percent for those recipients continuously enrolled for at least
1050 8 months. The agency shall develop a method by which the EPSDT
1051 screening rate shall be calculated. For any entity which does
1052 not achieve the annual 60 percent rate, the entity must submit a
1053 corrective action plan for the agency’s approval. If the entity
1054 does not meet the standard established in the corrective action
1055 plan during the specified timeframe, the agency is authorized to
1056 impose appropriate contract sanctions. At least annually, the
1057 agency shall publicly release the EPSDT Services screening rates
1058 of each entity it has contracted with on a prepaid basis to
1059 serve Medicaid recipients. This subsection expires October 1,
1060 2014.
1061 (28) The agency shall perform enrollments and
1062 disenrollments for Medicaid recipients who are eligible for
1063 MediPass or managed care plans. Notwithstanding the prohibition
1064 contained in paragraph (20)(f), managed care plans may perform
1065 preenrollments of Medicaid recipients under the supervision of
1066 the agency or its agents. For the purposes of this section, the
1067 term “preenrollment” means the provision of marketing and
1068 educational materials to a Medicaid recipient and assistance in
1069 completing the application forms, but does not include actual
1070 enrollment into a managed care plan. An application for
1071 enrollment may not be deemed complete until the agency or its
1072 agent verifies that the recipient made an informed, voluntary
1073 choice. The agency, in cooperation with the Department of
1074 Children and Families, may test new marketing initiatives to
1075 inform Medicaid recipients about their managed care options at
1076 selected sites. The agency may contract with a third party to
1077 perform managed care plan and MediPass enrollment and
1078 disenrollment services for Medicaid recipients and may adopt
1079 rules to administer such services. The agency may adjust the
1080 capitation rate only to cover the costs of a third-party
1081 enrollment and disenrollment contract, and for agency
1082 supervision and management of the managed care plan enrollment
1083 and disenrollment contract. This subsection expires October 1,
1084 2014.
1085 (29) Any lists of providers made available to Medicaid
1086 recipients, MediPass enrollees, or managed care plan enrollees
1087 shall be arranged alphabetically showing the provider’s name and
1088 specialty and, separately, by specialty in alphabetical order.
1089 This subsection expires October 1, 2014.
1090 (30) The agency shall establish an enhanced managed care
1091 quality assurance oversight function, to include at least the
1092 following components:
1093 (a) At least quarterly analysis and followup, including
1094 sanctions as appropriate, of managed care participant
1095 utilization of services.
1096 (b) At least quarterly analysis and followup, including
1097 sanctions as appropriate, of quality findings of the Medicaid
1098 peer review organization and other external quality assurance
1099 programs.
1100 (c) At least quarterly analysis and followup, including
1101 sanctions as appropriate, of the fiscal viability of managed
1102 care plans.
1103 (d) At least quarterly analysis and followup, including
1104 sanctions as appropriate, of managed care participant
1105 satisfaction and disenrollment surveys.
1106 (e) The agency shall conduct regular and ongoing Medicaid
1107 recipient satisfaction surveys.
1108
1109 The analyses and followup activities conducted by the agency
1110 under its enhanced managed care quality assurance oversight
1111 function shall not duplicate the activities of accreditation
1112 reviewers for entities regulated under part III of chapter 641,
1113 but may include a review of the finding of such reviewers. This
1114 subsection expires October 1, 2014.
1115 (31) Each managed care plan that is under contract with the
1116 agency to provide health care services to Medicaid recipients
1117 shall annually conduct a background check with the Department of
1118 Law Enforcement of all persons with ownership interest of 5
1119 percent or more or executive management responsibility for the
1120 managed care plan and shall submit to the agency information
1121 concerning any such person who has been found guilty of,
1122 regardless of adjudication, or has entered a plea of nolo
1123 contendere or guilty to, any of the offenses listed in s.
1124 435.04. This subsection expires October 1, 2014.
1125 (32) The agency shall, by rule, develop a process whereby a
1126 Medicaid managed care plan enrollee who wishes to enter hospice
1127 care may be disenrolled from the managed care plan within 24
1128 hours after contacting the agency regarding such request. The
1129 agency rule shall include a methodology for the agency to recoup
1130 managed care plan payments on a pro rata basis if payment has
1131 been made for the enrollment month when disenrollment occurs.
1132 This subsection expires October 1, 2014.
1133 (33) The agency and entities that contract with the agency
1134 to provide health care services to Medicaid recipients under
1135 this section or ss. 409.91211 and 409.9122 must comply with the
1136 provisions of s. 641.513 in providing emergency services and
1137 care to Medicaid recipients and MediPass recipients. Where
1138 feasible, safe, and cost-effective, the agency shall encourage
1139 hospitals, emergency medical services providers, and other
1140 public and private health care providers to work together in
1141 their local communities to enter into agreements or arrangements
1142 to ensure access to alternatives to emergency services and care
1143 for those Medicaid recipients who need nonemergent care. The
1144 agency shall coordinate with hospitals, emergency medical
1145 services providers, private health plans, capitated managed care
1146 networks as established in s. 409.91211, and other public and
1147 private health care providers to implement the provisions of ss.
1148 395.1041(7), 409.91255(3)(g), 627.6405, and 641.31097 to develop
1149 and implement emergency department diversion programs for
1150 Medicaid recipients. This subsection expires October 1, 2014.
1151 (34) All entities providing health care services to
1152 Medicaid recipients shall make available, and encourage all
1153 pregnant women and mothers with infants to receive, and provide
1154 documentation in the medical records to reflect, the following:
1155 (a) Healthy Start prenatal or infant screening.
1156 (b) Healthy Start care coordination, when screening or
1157 other factors indicate need.
1158 (c) Healthy Start enhanced services in accordance with the
1159 prenatal or infant screening results.
1160 (d) Immunizations in accordance with recommendations of the
1161 Advisory Committee on Immunization Practices of the United
1162 States Public Health Service and the American Academy of
1163 Pediatrics, as appropriate.
1164 (e) Counseling and services for family planning to all
1165 women and their partners.
1166 (f) A scheduled postpartum visit for the purpose of
1167 voluntary family planning, to include discussion of all methods
1168 of contraception, as appropriate.
1169 (g) Referral to the Special Supplemental Nutrition Program
1170 for Women, Infants, and Children (WIC).
1171
1172 This subsection expires October 1, 2014.
1173 (35) Any entity that provides Medicaid prepaid health plan
1174 services shall ensure the appropriate coordination of health
1175 care services with an assisted living facility in cases where a
1176 Medicaid recipient is both a member of the entity’s prepaid
1177 health plan and a resident of the assisted living facility. If
1178 the entity is at risk for Medicaid targeted case management and
1179 behavioral health services, the entity shall inform the assisted
1180 living facility of the procedures to follow should an emergent
1181 condition arise. This subsection expires October 1, 2014.
1182 (36) The agency shall enter into agreements with not-for
1183 profit organizations based in this state for the purpose of
1184 providing vision screening. This subsection expires October 1,
1185 2014.
1186 (8)(37)(a) The agency shall implement a Medicaid
1187 prescribed-drug spending-control program that includes the
1188 following components:
1189 1. A Medicaid preferred drug list, which shall be a listing
1190 of cost-effective therapeutic options recommended by the
1191 Medicaid Pharmacy and Therapeutics Committee established
1192 pursuant to s. 409.91195 and adopted by the agency for each
1193 therapeutic class on the preferred drug list. At the discretion
1194 of the committee, and when feasible, the preferred drug list
1195 should include at least two products in a therapeutic class. The
1196 agency may post the preferred drug list and updates to the list
1197 on an Internet website without following the rulemaking
1198 procedures of chapter 120. Antiretroviral agents are excluded
1199 from the preferred drug list. The agency shall also limit the
1200 amount of a prescribed drug dispensed to no more than a 34-day
1201 supply unless the drug products’ smallest marketed package is
1202 greater than a 34-day supply, or the drug is determined by the
1203 agency to be a maintenance drug in which case a 100-day maximum
1204 supply may be authorized. The agency may seek any federal
1205 waivers necessary to implement these cost-control programs and
1206 to continue participation in the federal Medicaid rebate
1207 program, or alternatively to negotiate state-only manufacturer
1208 rebates. The agency may adopt rules to administer this
1209 subparagraph. The agency shall continue to provide unlimited
1210 contraceptive drugs and items. The agency must establish
1211 procedures to ensure that:
1212 a. There is a response to a request for prior consultation
1213 by telephone or other telecommunication device within 24 hours
1214 after receipt of a request for prior consultation; and
1215 b. A 72-hour supply of the drug prescribed is provided in
1216 an emergency or when the agency does not provide a response
1217 within 24 hours as required by sub-subparagraph a.
1218 2. Reimbursement to pharmacies for Medicaid prescribed
1219 drugs shall be set at the lowest of: the average wholesale price
1220 (AWP) minus 16.4 percent, the wholesaler acquisition cost (WAC)
1221 plus 1.5 percent, the federal upper limit (FUL), the state
1222 maximum allowable cost (SMAC), or the usual and customary (UAC)
1223 charge billed by the provider.
1224 3. The agency shall develop and implement a process for
1225 managing the drug therapies of Medicaid recipients who are using
1226 significant numbers of prescribed drugs each month. The
1227 management process may include, but is not limited to,
1228 comprehensive, physician-directed medical-record reviews, claims
1229 analyses, and case evaluations to determine the medical
1230 necessity and appropriateness of a patient’s treatment plan and
1231 drug therapies. The agency may contract with a private
1232 organization to provide drug-program-management services. The
1233 Medicaid drug benefit management program shall include
1234 initiatives to manage drug therapies for HIV/AIDS patients,
1235 patients using 20 or more unique prescriptions in a 180-day
1236 period, and the top 1,000 patients in annual spending. The
1237 agency shall enroll any Medicaid recipient in the drug benefit
1238 management program if he or she meets the specifications of this
1239 provision and is not enrolled in a Medicaid health maintenance
1240 organization.
1241 4. The agency may limit the size of its pharmacy network
1242 based on need, competitive bidding, price negotiations,
1243 credentialing, or similar criteria. The agency shall give
1244 special consideration to rural areas in determining the size and
1245 location of pharmacies included in the Medicaid pharmacy
1246 network. A pharmacy credentialing process may include criteria
1247 such as a pharmacy’s full-service status, location, size,
1248 patient educational programs, patient consultation, disease
1249 management services, and other characteristics. The agency may
1250 impose a moratorium on Medicaid pharmacy enrollment if it is
1251 determined that it has a sufficient number of Medicaid
1252 participating providers. The agency must allow dispensing
1253 practitioners to participate as a part of the Medicaid pharmacy
1254 network regardless of the practitioner’s proximity to any other
1255 entity that is dispensing prescription drugs under the Medicaid
1256 program. A dispensing practitioner must meet all credentialing
1257 requirements applicable to his or her practice, as determined by
1258 the agency.
1259 5. The agency shall develop and implement a program that
1260 requires Medicaid practitioners who prescribe drugs to use a
1261 counterfeit-proof prescription pad for Medicaid prescriptions.
1262 The agency shall require the use of standardized counterfeit
1263 proof prescription pads by Medicaid-participating prescribers or
1264 prescribers who write prescriptions for Medicaid recipients. The
1265 agency may implement the program in targeted geographic areas or
1266 statewide.
1267 6. The agency may enter into arrangements that require
1268 manufacturers of generic drugs prescribed to Medicaid recipients
1269 to provide rebates of at least 15.1 percent of the average
1270 manufacturer price for the manufacturer’s generic products.
1271 These arrangements shall require that if a generic-drug
1272 manufacturer pays federal rebates for Medicaid-reimbursed drugs
1273 at a level below 15.1 percent, the manufacturer must provide a
1274 supplemental rebate to the state in an amount necessary to
1275 achieve a 15.1-percent rebate level.
1276 7. The agency may establish a preferred drug list as
1277 described in this subsection, and, pursuant to the establishment
1278 of such preferred drug list, negotiate supplemental rebates from
1279 manufacturers that are in addition to those required by Title
1280 XIX of the Social Security Act and at no less than 14 percent of
1281 the average manufacturer price as defined in 42 U.S.C. s. 1936
1282 on the last day of a quarter unless the federal or supplemental
1283 rebate, or both, equals or exceeds 29 percent. There is no upper
1284 limit on the supplemental rebates the agency may negotiate. The
1285 agency may determine that specific products, brand-name or
1286 generic, are competitive at lower rebate percentages. Agreement
1287 to pay the minimum supplemental rebate percentage guarantees a
1288 manufacturer that the Medicaid Pharmaceutical and Therapeutics
1289 Committee will consider a product for inclusion on the preferred
1290 drug list. However, a pharmaceutical manufacturer is not
1291 guaranteed placement on the preferred drug list by simply paying
1292 the minimum supplemental rebate. Agency decisions will be made
1293 on the clinical efficacy of a drug and recommendations of the
1294 Medicaid Pharmaceutical and Therapeutics Committee, as well as
1295 the price of competing products minus federal and state rebates.
1296 The agency may contract with an outside agency or contractor to
1297 conduct negotiations for supplemental rebates. For the purposes
1298 of this section, the term “supplemental rebates” means cash
1299 rebates. Value-added programs as a substitution for supplemental
1300 rebates are prohibited. The agency may seek any federal waivers
1301 to implement this initiative.
1302 8. The agency shall expand home delivery of pharmacy
1303 products. The agency may amend the state plan and issue a
1304 procurement, as necessary, in order to implement this program.
1305 The procurements must include agreements with a pharmacy or
1306 pharmacies located in the state to provide mail order delivery
1307 services at no cost to the recipients who elect to receive home
1308 delivery of pharmacy products. The procurement must focus on
1309 serving recipients with chronic diseases for which pharmacy
1310 expenditures represent a significant portion of Medicaid
1311 pharmacy expenditures or which impact a significant portion of
1312 the Medicaid population. The agency may seek and implement any
1313 federal waivers necessary to implement this subparagraph.
1314 9. The agency shall limit to one dose per month any drug
1315 prescribed to treat erectile dysfunction.
1316 10.a. The agency may implement a Medicaid behavioral drug
1317 management system. The agency may contract with a vendor that
1318 has experience in operating behavioral drug management systems
1319 to implement this program. The agency may seek federal waivers
1320 to implement this program.
1321 b. The agency, in conjunction with the Department of
1322 Children and Families, may implement the Medicaid behavioral
1323 drug management system that is designed to improve the quality
1324 of care and behavioral health prescribing practices based on
1325 best practice guidelines, improve patient adherence to
1326 medication plans, reduce clinical risk, and lower prescribed
1327 drug costs and the rate of inappropriate spending on Medicaid
1328 behavioral drugs. The program may include the following
1329 elements:
1330 (I) Provide for the development and adoption of best
1331 practice guidelines for behavioral health-related drugs such as
1332 antipsychotics, antidepressants, and medications for treating
1333 bipolar disorders and other behavioral conditions; translate
1334 them into practice; review behavioral health prescribers and
1335 compare their prescribing patterns to a number of indicators
1336 that are based on national standards; and determine deviations
1337 from best practice guidelines.
1338 (II) Implement processes for providing feedback to and
1339 educating prescribers using best practice educational materials
1340 and peer-to-peer consultation.
1341 (III) Assess Medicaid beneficiaries who are outliers in
1342 their use of behavioral health drugs with regard to the numbers
1343 and types of drugs taken, drug dosages, combination drug
1344 therapies, and other indicators of improper use of behavioral
1345 health drugs.
1346 (IV) Alert prescribers to patients who fail to refill
1347 prescriptions in a timely fashion, are prescribed multiple same
1348 class behavioral health drugs, and may have other potential
1349 medication problems.
1350 (V) Track spending trends for behavioral health drugs and
1351 deviation from best practice guidelines.
1352 (VI) Use educational and technological approaches to
1353 promote best practices, educate consumers, and train prescribers
1354 in the use of practice guidelines.
1355 (VII) Disseminate electronic and published materials.
1356 (VIII) Hold statewide and regional conferences.
1357 (IX) Implement a disease management program with a model
1358 quality-based medication component for severely mentally ill
1359 individuals and emotionally disturbed children who are high
1360 users of care.
1361 11. The agency shall implement a Medicaid prescription drug
1362 management system.
1363 a. The agency may contract with a vendor that has
1364 experience in operating prescription drug management systems in
1365 order to implement this system. Any management system that is
1366 implemented in accordance with this subparagraph must rely on
1367 cooperation between physicians and pharmacists to determine
1368 appropriate practice patterns and clinical guidelines to improve
1369 the prescribing, dispensing, and use of drugs in the Medicaid
1370 program. The agency may seek federal waivers to implement this
1371 program.
1372 b. The drug management system must be designed to improve
1373 the quality of care and prescribing practices based on best
1374 practice guidelines, improve patient adherence to medication
1375 plans, reduce clinical risk, and lower prescribed drug costs and
1376 the rate of inappropriate spending on Medicaid prescription
1377 drugs. The program must:
1378 (I) Provide for the adoption of best practice guidelines
1379 for the prescribing and use of drugs in the Medicaid program,
1380 including translating best practice guidelines into practice;
1381 reviewing prescriber patterns and comparing them to indicators
1382 that are based on national standards and practice patterns of
1383 clinical peers in their community, statewide, and nationally;
1384 and determine deviations from best practice guidelines.
1385 (II) Implement processes for providing feedback to and
1386 educating prescribers using best practice educational materials
1387 and peer-to-peer consultation.
1388 (III) Assess Medicaid recipients who are outliers in their
1389 use of a single or multiple prescription drugs with regard to
1390 the numbers and types of drugs taken, drug dosages, combination
1391 drug therapies, and other indicators of improper use of
1392 prescription drugs.
1393 (IV) Alert prescribers to recipients who fail to refill
1394 prescriptions in a timely fashion, are prescribed multiple drugs
1395 that may be redundant or contraindicated, or may have other
1396 potential medication problems.
1397 12. The agency may contract for drug rebate administration,
1398 including, but not limited to, calculating rebate amounts,
1399 invoicing manufacturers, negotiating disputes with
1400 manufacturers, and maintaining a database of rebate collections.
1401 13. The agency may specify the preferred daily dosing form
1402 or strength for the purpose of promoting best practices with
1403 regard to the prescribing of certain drugs as specified in the
1404 General Appropriations Act and ensuring cost-effective
1405 prescribing practices.
1406 14. The agency may require prior authorization for
1407 Medicaid-covered prescribed drugs. The agency may prior
1408 authorize the use of a product:
1409 a. For an indication not approved in labeling;
1410 b. To comply with certain clinical guidelines; or
1411 c. If the product has the potential for overuse, misuse, or
1412 abuse.
1413
1414 The agency may require the prescribing professional to provide
1415 information about the rationale and supporting medical evidence
1416 for the use of a drug. The agency shall post prior
1417 authorization, step-edit criteria and protocol, and updates to
1418 the list of drugs that are subject to prior authorization on the
1419 agency’s Internet website within 21 days after the prior
1420 authorization and step-edit criteria and protocol and updates
1421 are approved by the agency. For purposes of this subparagraph,
1422 the term “step-edit” means an automatic electronic review of
1423 certain medications subject to prior authorization.
1424 15. The agency, in conjunction with the Pharmaceutical and
1425 Therapeutics Committee, may require age-related prior
1426 authorizations for certain prescribed drugs. The agency may
1427 preauthorize the use of a drug for a recipient who may not meet
1428 the age requirement or may exceed the length of therapy for use
1429 of this product as recommended by the manufacturer and approved
1430 by the Food and Drug Administration. Prior authorization may
1431 require the prescribing professional to provide information
1432 about the rationale and supporting medical evidence for the use
1433 of a drug.
1434 16. The agency shall implement a step-therapy prior
1435 authorization approval process for medications excluded from the
1436 preferred drug list. Medications listed on the preferred drug
1437 list must be used within the previous 12 months before the
1438 alternative medications that are not listed. The step-therapy
1439 prior authorization may require the prescriber to use the
1440 medications of a similar drug class or for a similar medical
1441 indication unless contraindicated in the Food and Drug
1442 Administration labeling. The trial period between the specified
1443 steps may vary according to the medical indication. The step
1444 therapy approval process shall be developed in accordance with
1445 the committee as stated in s. 409.91195(7) and (8). A drug
1446 product may be approved without meeting the step-therapy prior
1447 authorization criteria if the prescribing physician provides the
1448 agency with additional written medical or clinical documentation
1449 that the product is medically necessary because:
1450 a. There is not a drug on the preferred drug list to treat
1451 the disease or medical condition which is an acceptable clinical
1452 alternative;
1453 b. The alternatives have been ineffective in the treatment
1454 of the beneficiary’s disease; or
1455 c. Based on historic evidence and known characteristics of
1456 the patient and the drug, the drug is likely to be ineffective,
1457 or the number of doses have been ineffective.
1458
1459 The agency shall work with the physician to determine the best
1460 alternative for the patient. The agency may adopt rules waiving
1461 the requirements for written clinical documentation for specific
1462 drugs in limited clinical situations.
1463 17. The agency shall implement a return and reuse program
1464 for drugs dispensed by pharmacies to institutional recipients,
1465 which includes payment of a $5 restocking fee for the
1466 implementation and operation of the program. The return and
1467 reuse program shall be implemented electronically and in a
1468 manner that promotes efficiency. The program must permit a
1469 pharmacy to exclude drugs from the program if it is not
1470 practical or cost-effective for the drug to be included and must
1471 provide for the return to inventory of drugs that cannot be
1472 credited or returned in a cost-effective manner. The agency
1473 shall determine if the program has reduced the amount of
1474 Medicaid prescription drugs which are destroyed on an annual
1475 basis and if there are additional ways to ensure more
1476 prescription drugs are not destroyed which could safely be
1477 reused.
1478 (b) The agency shall implement this subsection to the
1479 extent that funds are appropriated to administer the Medicaid
1480 prescribed-drug spending-control program. The agency may
1481 contract all or any part of this program to private
1482 organizations.
1483 (c) The agency shall submit quarterly reports to the
1484 Governor, the President of the Senate, and the Speaker of the
1485 House of Representatives which must include, but need not be
1486 limited to, the progress made in implementing this subsection
1487 and its effect on Medicaid prescribed-drug expenditures.
1488 (9)(38) Notwithstanding the provisions of chapter 287, the
1489 agency may, at its discretion, renew a contract or contracts for
1490 fiscal intermediary services one or more times for such periods
1491 as the agency may decide; however, all such renewals may not
1492 combine to exceed a total period longer than the term of the
1493 original contract.
1494 (39) The agency shall establish a demonstration project in
1495 Miami-Dade County of a long-term-care facility and a psychiatric
1496 facility licensed pursuant to chapter 395 to improve access to
1497 health care for a predominantly minority, medically underserved,
1498 and medically complex population and to evaluate alternatives to
1499 nursing home care and general acute care for such population.
1500 Such project is to be located in a health care condominium and
1501 collocated with licensed facilities providing a continuum of
1502 care. These projects are not subject to the provisions of s.
1503 408.036 or s. 408.039. This subsection expires October 1, 2013.
1504 (40) The agency shall develop and implement a utilization
1505 management program for Medicaid-eligible recipients for the
1506 management of occupational, physical, respiratory, and speech
1507 therapies. The agency shall establish a utilization program that
1508 may require prior authorization in order to ensure medically
1509 necessary and cost-effective treatments. The program shall be
1510 operated in accordance with a federally approved waiver program
1511 or state plan amendment. The agency may seek a federal waiver or
1512 state plan amendment to implement this program. The agency may
1513 also competitively procure these services from an outside vendor
1514 on a regional or statewide basis. This subsection expires
1515 October 1, 2014.
1516 (41)(a) The agency shall contract on a prepaid or fixed-sum
1517 basis with appropriately licensed prepaid dental health plans to
1518 provide dental services. This paragraph expires October 1, 2014.
1519 (b) Notwithstanding paragraph (a) and for the 2012-2013
1520 fiscal year only, the agency is authorized to provide a Medicaid
1521 prepaid dental health program in Miami-Dade County. For all
1522 other counties, the agency may not limit dental services to
1523 prepaid plans and must allow qualified dental providers to
1524 provide dental services under Medicaid on a fee-for-service
1525 reimbursement methodology. The agency may seek any necessary
1526 revisions or amendments to the state plan or federal waivers in
1527 order to implement this paragraph. The agency shall terminate
1528 existing contracts as needed to implement this paragraph. This
1529 paragraph expires July 1, 2013.
1530 (42) The Agency for Health Care Administration shall ensure
1531 that any Medicaid managed care plan as defined in s.
1532 409.9122(2)(f), whether paid on a capitated basis or a shared
1533 savings basis, is cost-effective. For purposes of this
1534 subsection, the term “cost-effective” means that a network’s
1535 per-member, per-month costs to the state, including, but not
1536 limited to, fee-for-service costs, administrative costs, and
1537 case-management fees, if any, must be no greater than the
1538 state’s costs associated with contracts for Medicaid services
1539 established under subsection (3), which may be adjusted for
1540 health status. The agency shall conduct actuarially sound
1541 adjustments for health status in order to ensure such cost
1542 effectiveness and shall annually publish the results on its
1543 Internet website. Contracts established pursuant to this
1544 subsection which are not cost-effective may not be renewed. This
1545 subsection expires October 1, 2014.
1546 (43) Subject to the availability of funds, the agency shall
1547 mandate a recipient’s participation in a provider lock-in
1548 program, when appropriate, if a recipient is found by the agency
1549 to have used Medicaid goods or services at a frequency or amount
1550 not medically necessary, limiting the receipt of goods or
1551 services to medically necessary providers after the 21-day
1552 appeal process has ended, for a period of not less than 1 year.
1553 The lock-in programs shall include, but are not limited to,
1554 pharmacies, medical doctors, and infusion clinics. The
1555 limitation does not apply to emergency services and care
1556 provided to the recipient in a hospital emergency department.
1557 The agency shall seek any federal waivers necessary to implement
1558 this subsection. The agency shall adopt any rules necessary to
1559 comply with or administer this subsection. This subsection
1560 expires October 1, 2014.
1561 (10)(44) The agency shall seek a federal waiver for
1562 permission to terminate the eligibility of a Medicaid recipient
1563 who has been found to have committed fraud, through judicial or
1564 administrative determination, two times in a period of 5 years.
1565 (11)(45)(a) A provider is not entitled to enrollment in the
1566 Medicaid provider network. The agency may implement a Medicaid
1567 fee-for-service provider network controls, including, but not
1568 limited to, competitive procurement and provider credentialing.
1569 If a credentialing process is used, the agency may limit its
1570 provider network based upon the following considerations:
1571 beneficiary access to care, provider availability, provider
1572 quality standards and quality assurance processes, cultural
1573 competency, demographic characteristics of beneficiaries,
1574 practice standards, service wait times, provider turnover,
1575 provider licensure and accreditation history, program integrity
1576 history, peer review, Medicaid policy and billing compliance
1577 records, clinical and medical record audit findings, and such
1578 other areas that are considered necessary by the agency to
1579 ensure the integrity of the program.
1580 (b) The agency shall limit its network of durable medical
1581 equipment and medical supply providers. For dates of service
1582 after January 1, 2009, the agency shall limit payment for
1583 durable medical equipment and supplies to providers that meet
1584 all the requirements of this paragraph.
1585 1. Providers must be accredited by a Centers for Medicare
1586 and Medicaid Services deemed accreditation organization for
1587 suppliers of durable medical equipment, prosthetics, orthotics,
1588 and supplies. The provider must maintain accreditation and is
1589 subject to unannounced reviews by the accrediting organization.
1590 2. Providers must provide the services or supplies directly
1591 to the Medicaid recipient or caregiver at the provider location
1592 or recipient’s residence or send the supplies directly to the
1593 recipient’s residence with receipt of mailed delivery.
1594 Subcontracting or consignment of the service or supply to a
1595 third party is prohibited.
1596 3. Notwithstanding subparagraph 2., a durable medical
1597 equipment provider may store nebulizers at a physician’s office
1598 for the purpose of having the physician’s staff issue the
1599 equipment if it meets all of the following conditions:
1600 a. The physician must document the medical necessity and
1601 need to prevent further deterioration of the patient’s
1602 respiratory status by the timely delivery of the nebulizer in
1603 the physician’s office.
1604 b. The durable medical equipment provider must have written
1605 documentation of the competency and training by a Florida
1606 licensed registered respiratory therapist of any durable medical
1607 equipment staff who participate in the training of physician
1608 office staff for the use of nebulizers, including cleaning,
1609 warranty, and special needs of patients.
1610 c. The physician’s office must have documented the training
1611 and competency of any staff member who initiates the delivery of
1612 nebulizers to patients. The durable medical equipment provider
1613 must maintain copies of all physician office training.
1614 d. The physician’s office must maintain inventory records
1615 of stored nebulizers, including documentation of the durable
1616 medical equipment provider source.
1617 e. A physician contracted with a Medicaid durable medical
1618 equipment provider may not have a financial relationship with
1619 that provider or receive any financial gain from the delivery of
1620 nebulizers to patients.
1621 4. Providers must have a physical business location and a
1622 functional landline business phone. The location must be within
1623 the state or not more than 50 miles from the Florida state line.
1624 The agency may make exceptions for providers of durable medical
1625 equipment or supplies not otherwise available from other
1626 enrolled providers located within the state.
1627 5. Physical business locations must be clearly identified
1628 as a business that furnishes durable medical equipment or
1629 medical supplies by signage that can be read from 20 feet away.
1630 The location must be readily accessible to the public during
1631 normal, posted business hours and must operate at least 5 hours
1632 per day and at least 5 days per week, with the exception of
1633 scheduled and posted holidays. The location may not be located
1634 within or at the same numbered street address as another
1635 enrolled Medicaid durable medical equipment or medical supply
1636 provider or as an enrolled Medicaid pharmacy that is also
1637 enrolled as a durable medical equipment provider. A licensed
1638 orthotist or prosthetist that provides only orthotic or
1639 prosthetic devices as a Medicaid durable medical equipment
1640 provider is exempt from this paragraph.
1641 6. Providers must maintain a stock of durable medical
1642 equipment and medical supplies on site that is readily available
1643 to meet the needs of the durable medical equipment business
1644 location’s customers.
1645 7. Providers must provide a surety bond of $50,000 for each
1646 provider location, up to a maximum of 5 bonds statewide or an
1647 aggregate bond of $250,000 statewide, as identified by Federal
1648 Employer Identification Number. Providers who post a statewide
1649 or an aggregate bond must identify all of their locations in any
1650 Medicaid durable medical equipment and medical supply provider
1651 enrollment application or bond renewal. Each provider location’s
1652 surety bond must be renewed annually and the provider must
1653 submit proof of renewal even if the original bond is a
1654 continuous bond. A licensed orthotist or prosthetist that
1655 provides only orthotic or prosthetic devices as a Medicaid
1656 durable medical equipment provider is exempt from the provisions
1657 in this paragraph.
1658 8. Providers must obtain a level 2 background screening, in
1659 accordance with chapter 435 and s. 408.809, for each provider
1660 employee in direct contact with or providing direct services to
1661 recipients of durable medical equipment and medical supplies in
1662 their homes. This requirement includes, but is not limited to,
1663 repair and service technicians, fitters, and delivery staff. The
1664 provider shall pay for the cost of the background screening.
1665 9. The following providers are exempt from subparagraphs 1.
1666 and 7.:
1667 a. Durable medical equipment providers owned and operated
1668 by a government entity.
1669 b. Durable medical equipment providers that are operating
1670 within a pharmacy that is currently enrolled as a Medicaid
1671 pharmacy provider.
1672 c. Active, Medicaid-enrolled orthopedic physician groups,
1673 primarily owned by physicians, which provide only orthotic and
1674 prosthetic devices.
1675 (46) The agency shall contract with established minority
1676 physician networks that provide services to historically
1677 underserved minority patients. The networks must provide cost
1678 effective Medicaid services, comply with the requirements to be
1679 a MediPass provider, and provide their primary care physicians
1680 with access to data and other management tools necessary to
1681 assist them in ensuring the appropriate use of services,
1682 including inpatient hospital services and pharmaceuticals.
1683 (a) The agency shall provide for the development and
1684 expansion of minority physician networks in each service area to
1685 provide services to Medicaid recipients who are eligible to
1686 participate under federal law and rules.
1687 (b) The agency shall reimburse each minority physician
1688 network as a fee-for-service provider, including the case
1689 management fee for primary care, if any, or as a capitated rate
1690 provider for Medicaid services. Any savings shall be shared with
1691 the minority physician networks pursuant to the contract.
1692 (c) For purposes of this subsection, the term “cost
1693 effective” means that a network’s per-member, per-month costs to
1694 the state, including, but not limited to, fee-for-service costs,
1695 administrative costs, and case-management fees, if any, must be
1696 no greater than the state’s costs associated with contracts for
1697 Medicaid services established under subsection (3), which shall
1698 be actuarially adjusted for case mix, model, and service area.
1699 The agency shall conduct actuarially sound audits adjusted for
1700 case mix and model in order to ensure such cost-effectiveness
1701 and shall annually publish the audit results on its Internet
1702 website. Contracts established pursuant to this subsection which
1703 are not cost-effective may not be renewed.
1704 (d) The agency may apply for any federal waivers needed to
1705 implement this subsection.
1706
1707 This subsection expires October 1, 2014.
1708 (12)(47) To the extent permitted by federal law and as
1709 allowed under s. 409.906, the agency shall provide reimbursement
1710 for emergency mental health care services for Medicaid
1711 recipients in crisis stabilization facilities licensed under s.
1712 394.875 as long as those services are less expensive than the
1713 same services provided in a hospital setting.
1714 (13)(48) The agency shall work with the Agency for Persons
1715 with Disabilities to develop a home and community-based waiver
1716 to serve children and adults who are diagnosed with familial
1717 dysautonomia or Riley-Day syndrome caused by a mutation of the
1718 IKBKAP gene on chromosome 9. The agency shall seek federal
1719 waiver approval and implement the approved waiver subject to the
1720 availability of funds and any limitations provided in the
1721 General Appropriations Act. The agency may adopt rules to
1722 implement this waiver program.
1723 (14)(49) The agency shall implement a program of all
1724 inclusive care for children. The program of all-inclusive care
1725 for children shall be established to provide in-home hospice
1726 like support services to children diagnosed with a life
1727 threatening illness and enrolled in the Children’s Medical
1728 Services network to reduce hospitalizations as appropriate. The
1729 agency, in consultation with the Department of Health, may
1730 implement the program of all-inclusive care for children after
1731 obtaining approval from the Centers for Medicare and Medicaid
1732 Services.
1733 (15)(50) Before seeking an amendment to the state plan for
1734 purposes of implementing programs authorized by the Deficit
1735 Reduction Act of 2005, the agency shall notify the Legislature.
1736 (16)(51) The agency may not pay for psychotropic medication
1737 prescribed for a child in the Medicaid program without the
1738 express and informed consent of the child’s parent or legal
1739 guardian. The physician shall document the consent in the
1740 child’s medical record and provide the pharmacy with a signed
1741 attestation of this documentation with the prescription. The
1742 express and informed consent or court authorization for a
1743 prescription of psychotropic medication for a child in the
1744 custody of the Department of Children and Families shall be
1745 obtained pursuant to s. 39.407.
1746 Reviser’s note.—Amended to conform to the repeals of numerous
1747 subunits pursuant to their own terms, effective at various
1748 dates in 2013 and 2014. Material in existing s.
1749 409.912(4)(d)4. referencing s. 409.91211 was deleted to
1750 conform to the repeal of that section effective October 1,
1751 2014, by s. 20, ch. 2011-135, Laws of Florida, and
1752 confirmation of that repeal by this reviser’s bill. The
1753 reference in subsection (26), redesignated here as
1754 subsection (7), to the Medicaid Bureau of the Health Care
1755 Financing Administration was redesignated as the Centers
1756 for Medicare and Medicaid Services to conform to the
1757 renaming of the federal agency.
1758 Section 15. Section 409.91211, Florida Statutes, is
1759 repealed.
1760 Reviser’s note.—The cited section, which relates to the Medicaid
1761 managed care pilot program, was repealed by s. 20, ch.
1762 2011-135, Laws of Florida, effective October 1, 2014. Since
1763 the section was not repealed by a “current session” of the
1764 Legislature, it may be omitted from the 2015 Florida
1765 Statutes only through a reviser’s bill duly enacted by the
1766 Legislature. See s. 11.242(5)(b) and (i).
1767 Section 16. Section 409.9122, Florida Statutes, is amended
1768 to read:
1769 409.9122 Mandatory Medicaid managed care enrollment;
1770 programs and procedures.—
1771 (1) It is the intent of the Legislature that the MediPass
1772 program be cost-effective, provide quality health care, and
1773 improve access to health services, and that the program be
1774 statewide. This subsection expires October 1, 2014.
1775 (2)(a) The agency shall enroll in a managed care plan or
1776 MediPass all Medicaid recipients, except those Medicaid
1777 recipients who are: in an institution; enrolled in the Medicaid
1778 medically needy program; or eligible for both Medicaid and
1779 Medicare. Upon enrollment, individuals will be able to change
1780 their managed care option during the 90-day opt out period
1781 required by federal Medicaid regulations. The agency is
1782 authorized to seek the necessary Medicaid state plan amendment
1783 to implement this policy. However, to the extent permitted by
1784 federal law, the agency may enroll in a managed care plan or
1785 MediPass a Medicaid recipient who is exempt from mandatory
1786 managed care enrollment, provided that:
1787 1. The recipient’s decision to enroll in a managed care
1788 plan or MediPass is voluntary;
1789 2. If the recipient chooses to enroll in a managed care
1790 plan, the agency has determined that the managed care plan
1791 provides specific programs and services which address the
1792 special health needs of the recipient; and
1793 3. The agency receives any necessary waivers from the
1794 federal Centers for Medicare and Medicaid Services.
1795
1796 School districts participating in the certified school match
1797 program pursuant to ss. 409.908(21) and 1011.70 shall be
1798 reimbursed by Medicaid, subject to the limitations of s.
1799 1011.70(1), for a Medicaid-eligible child participating in the
1800 services as authorized in s. 1011.70, as provided for in s.
1801 409.9071, regardless of whether the child is enrolled in
1802 MediPass or a managed care plan. Managed care plans shall make a
1803 good faith effort to execute agreements with school districts
1804 regarding the coordinated provision of services authorized under
1805 s. 1011.70. County health departments delivering school-based
1806 services pursuant to ss. 381.0056 and 381.0057 shall be
1807 reimbursed by Medicaid for the federal share for a Medicaid
1808 eligible child who receives Medicaid-covered services in a
1809 school setting, regardless of whether the child is enrolled in
1810 MediPass or a managed care plan. Managed care plans shall make a
1811 good faith effort to execute agreements with county health
1812 departments regarding the coordinated provision of services to a
1813 Medicaid-eligible child. To ensure continuity of care for
1814 Medicaid patients, the agency, the Department of Health, and the
1815 Department of Education shall develop procedures for ensuring
1816 that a student’s managed care plan or MediPass provider receives
1817 information relating to services provided in accordance with ss.
1818 381.0056, 381.0057, 409.9071, and 1011.70.
1819 (b) A Medicaid recipient may not be enrolled in or assigned
1820 to a managed care plan or MediPass unless the managed care plan
1821 or MediPass has complied with the quality-of-care standards
1822 specified in paragraphs (4)(a) and (b), respectively.
1823 (c) Medicaid recipients shall have a choice of managed care
1824 plans or MediPass. The Agency for Health Care Administration,
1825 the Department of Health, the Department of Children and
1826 Families, and the Department of Elderly Affairs shall cooperate
1827 to ensure that each Medicaid recipient receives clear and easily
1828 understandable information that meets the following
1829 requirements:
1830 1. Explains the concept of managed care, including
1831 MediPass.
1832 2. Provides information on the comparative performance of
1833 managed care plans and MediPass in the areas of quality,
1834 credentialing, preventive health programs, network size and
1835 availability, and patient satisfaction.
1836 3. Explains where additional information on each managed
1837 care plan and MediPass in the recipient’s area can be obtained.
1838 4. Explains that recipients have the right to choose their
1839 managed care coverage at the time they first enroll in Medicaid
1840 and again at regular intervals set by the agency. However, if a
1841 recipient does not choose a managed care plan or MediPass, the
1842 agency will assign the recipient to a managed care plan or
1843 MediPass according to the criteria specified in this section.
1844 5. Explains the recipient’s right to complain, file a
1845 grievance, or change managed care plans or MediPass providers if
1846 the recipient is not satisfied with the managed care plan or
1847 MediPass.
1848 (d) The agency shall develop a mechanism for providing
1849 information to Medicaid recipients for the purpose of making a
1850 managed care plan or MediPass selection. Examples of such
1851 mechanisms may include, but not be limited to, interactive
1852 information systems, mailings, and mass marketing materials.
1853 Managed care plans and MediPass providers are prohibited from
1854 providing inducements to Medicaid recipients to select their
1855 plans or from prejudicing Medicaid recipients against other
1856 managed care plans or MediPass providers.
1857 (e) Medicaid recipients who are already enrolled in a
1858 managed care plan or MediPass shall be offered the opportunity
1859 to change managed care plans or MediPass providers on a
1860 staggered basis, as defined by the agency. All Medicaid
1861 recipients shall have 30 days in which to make a choice of
1862 managed care plans or MediPass providers. Those Medicaid
1863 recipients who do not make a choice shall be assigned in
1864 accordance with paragraph (f). To facilitate continuity of care,
1865 for a Medicaid recipient who is also a recipient of Supplemental
1866 Security Income (SSI), prior to assigning the SSI recipient to a
1867 managed care plan or MediPass, the agency shall determine
1868 whether the SSI recipient has an ongoing relationship with a
1869 MediPass provider or managed care plan, and if so, the agency
1870 shall assign the SSI recipient to that MediPass provider or
1871 managed care plan. Those SSI recipients who do not have such a
1872 provider relationship shall be assigned to a managed care plan
1873 or MediPass provider in accordance with paragraph (f).
1874 (f) If a Medicaid recipient does not choose a managed care
1875 plan or MediPass provider, the agency shall assign the Medicaid
1876 recipient to a managed care plan or MediPass provider. Medicaid
1877 recipients eligible for managed care plan enrollment who are
1878 subject to mandatory assignment but who fail to make a choice
1879 shall be assigned to managed care plans until an enrollment of
1880 35 percent in MediPass and 65 percent in managed care plans, of
1881 all those eligible to choose managed care, is achieved. Once
1882 this enrollment is achieved, the assignments shall be divided in
1883 order to maintain an enrollment in MediPass and managed care
1884 plans which is in a 35 percent and 65 percent proportion,
1885 respectively. Thereafter, assignment of Medicaid recipients who
1886 fail to make a choice shall be based proportionally on the
1887 preferences of recipients who have made a choice in the previous
1888 period. Such proportions shall be revised at least quarterly to
1889 reflect an update of the preferences of Medicaid recipients. The
1890 agency shall disproportionately assign Medicaid-eligible
1891 recipients who are required to but have failed to make a choice
1892 of managed care plan or MediPass to the Children’s Medical
1893 Services Network as defined in s. 391.021, exclusive provider
1894 organizations, provider service networks, minority physician
1895 networks, and pediatric emergency department diversion programs
1896 authorized by this chapter or the General Appropriations Act, in
1897 such manner as the agency deems appropriate, until the agency
1898 has determined that the networks and programs have sufficient
1899 numbers to be operated economically. For purposes of this
1900 paragraph, when referring to assignment, the term “managed care
1901 plans” includes health maintenance organizations, exclusive
1902 provider organizations, provider service networks, minority
1903 physician networks, Children’s Medical Services Network, and
1904 pediatric emergency department diversion programs authorized by
1905 this chapter or the General Appropriations Act. When making
1906 assignments, the agency shall take into account the following
1907 criteria:
1908 1. A managed care plan has sufficient network capacity to
1909 meet the need of members.
1910 2. The managed care plan or MediPass has previously
1911 enrolled the recipient as a member, or one of the managed care
1912 plan’s primary care providers or MediPass providers has
1913 previously provided health care to the recipient.
1914 3. The agency has knowledge that the member has previously
1915 expressed a preference for a particular managed care plan or
1916 MediPass provider as indicated by Medicaid fee-for-service
1917 claims data, but has failed to make a choice.
1918 4. The managed care plan’s or MediPass primary care
1919 providers are geographically accessible to the recipient’s
1920 residence.
1921 (g) When more than one managed care plan or MediPass
1922 provider meets the criteria specified in paragraph (f), the
1923 agency shall make recipient assignments consecutively by family
1924 unit.
1925 (h) The agency may not engage in practices that are
1926 designed to favor one managed care plan over another or that are
1927 designed to influence Medicaid recipients to enroll in MediPass
1928 rather than in a managed care plan or to enroll in a managed
1929 care plan rather than in MediPass. This subsection does not
1930 prohibit the agency from reporting on the performance of
1931 MediPass or any managed care plan, as measured by performance
1932 criteria developed by the agency.
1933 (i) After a recipient has made his or her selection or has
1934 been enrolled in a managed care plan or MediPass, the recipient
1935 shall have 90 days to exercise the opportunity to voluntarily
1936 disenroll and select another managed care plan or MediPass.
1937 After 90 days, no further changes may be made except for good
1938 cause. Good cause includes, but is not limited to, poor quality
1939 of care, lack of access to necessary specialty services, an
1940 unreasonable delay or denial of service, or fraudulent
1941 enrollment. The agency shall develop criteria for good cause
1942 disenrollment for chronically ill and disabled populations who
1943 are assigned to managed care plans if more appropriate care is
1944 available through the MediPass program. The agency must make a
1945 determination as to whether cause exists. However, the agency
1946 may require a recipient to use the managed care plan’s or
1947 MediPass grievance process prior to the agency’s determination
1948 of cause, except in cases in which immediate risk of permanent
1949 damage to the recipient’s health is alleged. The grievance
1950 process, when utilized, must be completed in time to permit the
1951 recipient to disenroll by the first day of the second month
1952 after the month the disenrollment request was made. If the
1953 managed care plan or MediPass, as a result of the grievance
1954 process, approves an enrollee’s request to disenroll, the agency
1955 is not required to make a determination in the case. The agency
1956 must make a determination and take final action on a recipient’s
1957 request so that disenrollment occurs no later than the first day
1958 of the second month after the month the request was made. If the
1959 agency fails to act within the specified timeframe, the
1960 recipient’s request to disenroll is deemed to be approved as of
1961 the date agency action was required. Recipients who disagree
1962 with the agency’s finding that cause does not exist for
1963 disenrollment shall be advised of their right to pursue a
1964 Medicaid fair hearing to dispute the agency’s finding.
1965 (j) The agency shall apply for a federal waiver from the
1966 Centers for Medicare and Medicaid Services to lock eligible
1967 Medicaid recipients into a managed care plan or MediPass for 12
1968 months after an open enrollment period. After 12 months’
1969 enrollment, a recipient may select another managed care plan or
1970 MediPass provider. However, nothing shall prevent a Medicaid
1971 recipient from changing primary care providers within the
1972 managed care plan or MediPass program during the 12-month
1973 period.
1974 (k) When a Medicaid recipient does not choose a managed
1975 care plan or MediPass provider, the agency shall assign the
1976 Medicaid recipient to a managed care plan, except in those
1977 counties in which there are fewer than two managed care plans
1978 accepting Medicaid enrollees, in which case assignment shall be
1979 to a managed care plan or a MediPass provider. Medicaid
1980 recipients in counties with fewer than two managed care plans
1981 accepting Medicaid enrollees who are subject to mandatory
1982 assignment but who fail to make a choice shall be assigned to
1983 managed care plans until an enrollment of 35 percent in MediPass
1984 and 65 percent in managed care plans, of all those eligible to
1985 choose managed care, is achieved. Once that enrollment is
1986 achieved, the assignments shall be divided in order to maintain
1987 an enrollment in MediPass and managed care plans which is in a
1988 35 percent and 65 percent proportion, respectively. For purposes
1989 of this paragraph, when referring to assignment, the term
1990 “managed care plans” includes exclusive provider organizations,
1991 provider service networks, Children’s Medical Services Network,
1992 minority physician networks, and pediatric emergency department
1993 diversion programs authorized by this chapter or the General
1994 Appropriations Act. When making assignments, the agency shall
1995 take into account the following criteria:
1996 1. A managed care plan has sufficient network capacity to
1997 meet the need of members.
1998 2. The managed care plan or MediPass has previously
1999 enrolled the recipient as a member, or one of the managed care
2000 plan’s primary care providers or MediPass providers has
2001 previously provided health care to the recipient.
2002 3. The agency has knowledge that the member has previously
2003 expressed a preference for a particular managed care plan or
2004 MediPass provider as indicated by Medicaid fee-for-service
2005 claims data, but has failed to make a choice.
2006 4. The managed care plan’s or MediPass primary care
2007 providers are geographically accessible to the recipient’s
2008 residence.
2009 5. The agency has authority to make mandatory assignments
2010 based on quality of service and performance of managed care
2011 plans.
2012 (l) Notwithstanding chapter 287, the agency may renew cost
2013 effective contracts for choice counseling services once or more
2014 for such periods as the agency may decide. However, all such
2015 renewals may not combine to exceed a total period longer than
2016 the term of the original contract.
2017
2018 This subsection expires October 1, 2014.
2019 (3) Notwithstanding s. 409.961, if a Medicaid recipient is
2020 diagnosed with HIV/AIDS, the agency shall assign the recipient
2021 to a managed care plan that is a health maintenance organization
2022 authorized under chapter 641, that is under contract with the
2023 agency as an HIV/AIDS specialty plan as of January 1, 2013, and
2024 that offers a delivery system through a university-based
2025 teaching and research-oriented organization that specializes in
2026 providing health care services and treatment for individuals
2027 diagnosed with HIV/AIDS. This subsection applies to recipients
2028 who are subject to mandatory managed care enrollment and have
2029 failed to choose a managed care option.
2030 (4)(a) The agency shall establish quality-of-care standards
2031 for managed care plans. These standards shall be based upon, but
2032 are not limited to:
2033 1. Compliance with the accreditation requirements as
2034 provided in s. 641.512.
2035 2. Compliance with Early and Periodic Screening, Diagnosis,
2036 and Treatment screening requirements.
2037 3. The percentage of voluntary disenrollments.
2038 4. Immunization rates.
2039 5. Standards of the National Committee for Quality
2040 Assurance and other approved accrediting bodies.
2041 6. Recommendations of other authoritative bodies.
2042 7. Specific requirements of the Medicaid program, or
2043 standards designed to specifically assist the unique needs of
2044 Medicaid recipients.
2045 8. Compliance with the health quality improvement system as
2046 established by the agency, which incorporates standards and
2047 guidelines developed by the Medicaid Bureau of the Health Care
2048 Financing Administration as part of the quality assurance reform
2049 initiative.
2050 (b) For the MediPass program, the agency shall establish
2051 standards which are based upon, but are not limited to:
2052 1. Quality-of-care standards which are comparable to those
2053 required of managed care plans.
2054 2. Credentialing standards for MediPass providers.
2055 3. Compliance with Early and Periodic Screening, Diagnosis,
2056 and Treatment screening requirements.
2057 4. Immunization rates.
2058 5. Specific requirements of the Medicaid program, or
2059 standards designed to specifically assist the unique needs of
2060 Medicaid recipients.
2061
2062 This subsection expires October 1, 2014.
2063 (5)(a) Each female recipient may select as her primary care
2064 provider an obstetrician/gynecologist who has agreed to
2065 participate as a MediPass primary care case manager.
2066 (b) The agency shall establish a complaints and grievance
2067 process to assist Medicaid recipients enrolled in the MediPass
2068 program to resolve complaints and grievances. The agency shall
2069 investigate reports of quality-of-care grievances which remain
2070 unresolved to the satisfaction of the enrollee.
2071
2072 This subsection expires October 1, 2014.
2073 (6)(a) The agency shall work cooperatively with the Social
2074 Security Administration to identify beneficiaries who are
2075 jointly eligible for Medicare and Medicaid and shall develop
2076 cooperative programs to encourage these beneficiaries to enroll
2077 in a Medicare participating health maintenance organization or
2078 prepaid health plans.
2079 (b) The agency shall work cooperatively with the Department
2080 of Elderly Affairs to assess the potential cost-effectiveness of
2081 providing MediPass to beneficiaries who are jointly eligible for
2082 Medicare and Medicaid on a voluntary choice basis. If the agency
2083 determines that enrollment of these beneficiaries in MediPass
2084 has the potential for being cost-effective for the state, the
2085 agency shall offer MediPass to these beneficiaries on a
2086 voluntary choice basis in the counties where MediPass operates.
2087
2088 This subsection expires October 1, 2014.
2089 (7) MediPass enrolled recipients may receive up to 10
2090 visits of reimbursable services by participating Medicaid
2091 physicians licensed under chapter 460 and up to four visits of
2092 reimbursable services by participating Medicaid physicians
2093 licensed under chapter 461. Any further visits must be by prior
2094 authorization by the MediPass primary care provider. However,
2095 nothing in this subsection may be construed to increase the
2096 total number of visits or the total amount of dollars per year
2097 per person under current Medicaid rules, unless otherwise
2098 provided for in the General Appropriations Act. This subsection
2099 expires October 1, 2014.
2100 (8)(a) The agency shall develop and implement a
2101 comprehensive plan to ensure that recipients are adequately
2102 informed of their choices and rights under all Medicaid managed
2103 care programs and that Medicaid managed care programs meet
2104 acceptable standards of quality in patient care, patient
2105 satisfaction, and financial solvency.
2106 (b) The agency shall provide adequate means for informing
2107 patients of their choice and rights under a managed care plan at
2108 the time of eligibility determination.
2109 (c) The agency shall require managed care plans and
2110 MediPass providers to demonstrate and document plans and
2111 activities, as defined by rule, including outreach and followup,
2112 undertaken to ensure that Medicaid recipients receive the health
2113 care service to which they are entitled.
2114
2115 This subsection expires October 1, 2014.
2116 (9) The agency shall consult with Medicaid consumers and
2117 their representatives on an ongoing basis regarding measurements
2118 of patient satisfaction, procedures for resolving patient
2119 grievances, standards for ensuring quality of care, mechanisms
2120 for providing patient access to services, and policies affecting
2121 patient care. This subsection expires October 1, 2014.
2122 (10) The agency may extend eligibility for Medicaid
2123 recipients enrolled in licensed and accredited health
2124 maintenance organizations for the duration of the enrollment
2125 period or for 6 months, whichever is earlier, provided the
2126 agency certifies that such an offer will not increase state
2127 expenditures. This subsection expires October 1, 2013.
2128 (11) A managed care plan that has a Medicaid contract shall
2129 at least annually review each primary care physician’s active
2130 patient load and shall ensure that additional Medicaid
2131 recipients are not assigned to physicians who have a total
2132 active patient load of more than 3,000 patients. As used in this
2133 subsection, the term “active patient” means a patient who is
2134 seen by the same primary care physician, or by a physician
2135 assistant or advanced registered nurse practitioner under the
2136 supervision of the primary care physician, at least three times
2137 within a calendar year. Each primary care physician shall
2138 annually certify to the managed care plan whether or not his or
2139 her patient load exceeds the limits established under this
2140 subsection and the managed care plan shall accept such
2141 certification on face value as compliance with this subsection.
2142 The agency shall accept the managed care plan’s representations
2143 that it is in compliance with this subsection based on the
2144 certification of its primary care physicians, unless the agency
2145 has an objective indication that access to primary care is being
2146 compromised, such as receiving complaints or grievances relating
2147 to access to care. If the agency determines that an objective
2148 indication exists that access to primary care is being
2149 compromised, it may verify the patient load certifications
2150 submitted by the managed care plan’s primary care physicians and
2151 that the managed care plan is not assigning Medicaid recipients
2152 to primary care physicians who have an active patient load of
2153 more than 3,000 patients. This subsection expires October 1,
2154 2014.
2155 (12) Effective July 1, 2003, the agency shall adjust the
2156 enrollee assignment process of Medicaid managed prepaid health
2157 plans for those Medicaid managed prepaid plans operating in
2158 Miami-Dade County which have executed a contract with the agency
2159 for a minimum of 8 consecutive years in order for the Medicaid
2160 managed prepaid plan to maintain a minimum enrollment level of
2161 15,000 members per month. When assigning enrollees pursuant to
2162 this subsection, the agency shall give priority to providers
2163 that initially qualified under this subsection until such
2164 providers reach and maintain an enrollment level of 15,000
2165 members per month. A prepaid health plan that has a statewide
2166 Medicaid enrollment of 25,000 or more members is not eligible
2167 for enrollee assignments under this subsection. This subsection
2168 expires October 1, 2014.
2169 (2)(13) The agency shall include in its calculation of the
2170 hospital inpatient component of a Medicaid health maintenance
2171 organization’s capitation rate any special payments, including,
2172 but not limited to, upper payment limit or disproportionate
2173 share hospital payments, made to qualifying hospitals through
2174 the fee-for-service program. The agency may seek federal waiver
2175 approval or state plan amendment as needed to implement this
2176 adjustment.
2177 (3)(14) The agency shall develop a process to enable any
2178 recipient with access to employer-sponsored health care coverage
2179 to opt out of all eligible plans in the Medicaid program and to
2180 use Medicaid financial assistance to pay for the recipient’s
2181 share of cost in any such employer-sponsored coverage.
2182 Contingent on federal approval, the agency shall also enable
2183 recipients with access to other insurance or related products
2184 that provide access to health care services created pursuant to
2185 state law, including any plan or product available pursuant to
2186 the Florida Health Choices Program or any health exchange, to
2187 opt out. The amount of financial assistance provided for each
2188 recipient may not exceed the amount of the Medicaid premium that
2189 would have been paid to a plan for that recipient.
2190 (4)(15) The agency shall maintain and operate the Medicaid
2191 Encounter Data System to collect, process, store, and report on
2192 covered services provided to all Florida Medicaid recipients
2193 enrolled in prepaid managed care plans.
2194 (a) Prepaid managed care plans shall submit encounter data
2195 electronically in a format that complies with the Health
2196 Insurance Portability and Accountability Act provisions for
2197 electronic claims and in accordance with deadlines established
2198 by the agency. Prepaid managed care plans must certify that the
2199 data reported is accurate and complete.
2200 (b) The agency is responsible for validating the data
2201 submitted by the plans. The agency shall develop methods and
2202 protocols for ongoing analysis of the encounter data that
2203 adjusts for differences in characteristics of prepaid plan
2204 enrollees to allow comparison of service utilization among plans
2205 and against expected levels of use. The analysis shall be used
2206 to identify possible cases of systemic underutilization or
2207 denials of claims and inappropriate service utilization such as
2208 higher-than-expected emergency department encounters. The
2209 analysis shall provide periodic feedback to the plans and enable
2210 the agency to establish corrective action plans when necessary.
2211 One of the focus areas for the analysis shall be the use of
2212 prescription drugs.
2213 (5)(16) The agency may establish a per-member, per-month
2214 payment for Medicare Advantage Special Needs members that are
2215 also eligible for Medicaid as a mechanism for meeting the
2216 state’s cost-sharing obligation. The agency may also develop a
2217 per-member, per-month payment only for Medicaid-covered services
2218 for which the state is responsible. The agency shall develop a
2219 mechanism to ensure that such per-member, per-month payment
2220 enhances the value to the state and enrolled members by limiting
2221 cost sharing, enhances the scope of Medicare supplemental
2222 benefits that are equal to or greater than Medicaid coverage for
2223 select services, and improves care coordination.
2224 (6)(17) The agency shall establish, and managed care plans
2225 shall use, a uniform method of accounting for and reporting
2226 medical and nonmedical costs.
2227 (a) Managed care plans shall submit financial data
2228 electronically in a format that complies with the uniform
2229 accounting procedures established by the agency. Managed care
2230 plans must certify that the data reported is accurate and
2231 complete.
2232 (b) The agency is responsible for validating the financial
2233 data submitted by the plans. The agency shall develop methods
2234 and protocols for ongoing analysis of data that adjusts for
2235 differences in characteristics of plan enrollees to allow
2236 comparison among plans and against expected levels of
2237 expenditures. The analysis shall be used to identify possible
2238 cases of overspending on administrative costs or underspending
2239 on medical services.
2240 (7)(18) The agency shall establish and maintain an
2241 information system to make encounter data, financial data, and
2242 other measures of plan performance available to the public and
2243 any interested party.
2244 (a) Information submitted by the managed care plans shall
2245 be available online as well as in other formats.
2246 (b) Periodic agency reports shall be published that include
2247 summary as well as plan specific measures of financial
2248 performance and service utilization.
2249 (c) Any release of the financial and encounter data
2250 submitted by managed care plans shall ensure the confidentiality
2251 of personal health information.
2252 (8)(19) The agency may, on a case-by-case basis, exempt a
2253 recipient from mandatory enrollment in a managed care plan when
2254 the recipient has a unique, time-limited disease or condition
2255 related circumstance and managed care enrollment will interfere
2256 with ongoing care because the recipient’s provider does not
2257 participate in the managed care plans available in the
2258 recipient’s area.
2259 (20) The agency shall contract with a single provider
2260 service network to function as a managing entity for the
2261 MediPass program in all counties with fewer than two prepaid
2262 plans. The contractor shall be responsible for implementing
2263 preauthorization procedures, case management programs, and
2264 utilization management initiatives in order to improve care
2265 coordination and patient outcomes while reducing costs. The
2266 contractor may earn an administrative fee if the fee is less
2267 than any savings as determined by the reconciliation process
2268 under s. 409.912(4)(d)1. This subsection expires October 1,
2269 2014, or upon full implementation of the managed medical
2270 assistance program, whichever is sooner.
2271 (21) Subject to federal approval, the agency shall contract
2272 with a single provider service network to function as a third
2273 party administrator and managing entity for the Medically Needy
2274 program in all counties. The contractor shall provide care
2275 coordination and utilization management in order to achieve more
2276 cost-effective services for Medically Needy enrollees. To
2277 facilitate the care management functions of the provider service
2278 network, enrollment in the network shall be for a continuous 6
2279 month period or until the end of the contract between the
2280 provider service network and the agency, whichever is sooner.
2281 Beginning the second month after the determination of
2282 eligibility, the contractor may collect a monthly premium from
2283 each Medically Needy recipient provided the premium does not
2284 exceed the enrollee’s share of cost as determined by the
2285 Department of Children and Families. The contractor must provide
2286 a 90-day grace period before disenrolling a Medically Needy
2287 recipient for failure to pay premiums. The contractor may earn
2288 an administrative fee, if the fee is less than any savings
2289 determined by the reconciliation process pursuant to s.
2290 409.912(4)(d)1. Premium revenue collected from the recipients
2291 shall be deducted from the contractor’s earned savings. This
2292 subsection expires October 1, 2014, or upon full implementation
2293 of the managed medical assistance program, whichever is sooner.
2294 (9)(22) If required as a condition of a waiver, the agency
2295 may calculate a medical loss ratio for managed care plans. The
2296 calculation shall utilize uniform financial data collected from
2297 all plans and shall be computed for each plan on a statewide
2298 basis. The method for calculating the medical loss ratio shall
2299 meet the following criteria:
2300 (a) Except as provided in paragraphs (b) and (c),
2301 expenditures shall be classified in a manner consistent with 45
2302 C.F.R. part 158.
2303 (b) Funds provided by plans to graduate medical education
2304 institutions to underwrite the costs of residency positions
2305 shall be classified as medical expenditures, provided the
2306 funding is sufficient to sustain the positions for the number of
2307 years necessary to complete the residency requirements and the
2308 residency positions funded by the plans are active providers of
2309 care to Medicaid and uninsured patients.
2310 (c) Prior to final determination of the medical loss ratio
2311 for any period, a plan may contribute to a designated state
2312 trust fund for the purpose of supporting Medicaid and indigent
2313 care and have the contribution counted as a medical expenditure
2314 for the period.
2315 Reviser’s note.—Amended to conform to the repeals of numerous
2316 subunits pursuant to their own terms, effective at various
2317 dates in 2013 and 2014.
2318 Section 17. Subsection (15) of section 430.04, Florida
2319 Statutes, is repealed.
2320 Reviser’s note.—The cited subsection, which relates to
2321 authorization of the Department of Elderly Affairs to
2322 administer all Medicaid waivers and programs relating to
2323 elders and their appropriations, expired pursuant to its
2324 own terms, effective October 1, 2014.
2325 Section 18. Subsections (10), (11), and (12) of section
2326 430.502, Florida Statutes, are repealed.
2327 Reviser’s note.—The cited subsections relate to seeking of a
2328 federal waiver to implement a Medicaid home and community
2329 based waiver targeted to persons with Alzheimer’s disease
2330 to test the effectiveness of Alzheimer’s specific
2331 interventions to delay or to avoid institutional placement.
2332 Subsection (12) provides that authority to continue the
2333 waiver program is automatically eliminated at the close of
2334 the 2010 Regular Session of the Legislature unless further
2335 action is taken to continue it before such time.
2336 Section 19. Subsection (5) of section 443.131, Florida
2337 Statutes, is repealed.
2338 Reviser’s note.—The cited subsection, which relates to an
2339 additional rate for interest on federal advances received
2340 by the Unemployment Compensation Trust Fund, expired
2341 pursuant to its own terms, effective July 1, 2014.
2342 Section 20. Subsection (1) of section 576.061, Florida
2343 Statutes, is amended to read:
2344 576.061 Plant nutrient investigational allowances,
2345 deficiencies, and penalties.—
2346 (1) A commercial fertilizer is deemed deficient if the
2347 analysis of any nutrient is below the guarantee by an amount
2348 exceeding the investigational allowances. The department shall
2349 adopt rules, which shall take effect on July 1, 2014, that
2350 establish the investigational allowances used to determine
2351 whether a fertilizer is deficient in plant food.
2352 (a) Effective July 1, 2014, this paragraph and paragraphs
2353 (b)-(f) are repealed. Until July 1, 2014, investigational
2354 allowances shall be set as provided in paragraphs (b)-(f).
2355 (b) Primary plant nutrients; investigational allowances.—
2356
2357 GuaranteedPercentTotalNitrogenPercentAvailablePhosphatePercentPotashPercent
2358
2359 04 or less 0.49 0.67 0.41
2360 05 0.51 0.67 0.43
2361 06 0.52 0.67 0.47
2362 07 0.54 0.68 0.53
2363 08 0.55 0.68 0.60
2364 09 0.57 0.68 0.65
2365 10 0.58 0.69 0.70
2366 12 0.61 0.69 0.79
2367 14 0.63 0.70 0.87
2368 16 0.67 0.70 0.94
2369 18 0.70 0.71 1.01
2370 20 0.73 0.72 1.08
2371 22 0.75 0.72 1.15
2372 24 0.78 0.73 1.21
2373 26 0.81 0.73 1.27
2374 28 0.83 0.74 1.33
2375 30 0.86 0.75 1.39
2376 32 or more 0.88 0.76 1.44
2377
2378 For guarantees not listed, calculate the appropriate value by
2379 interpolation.
2380 (c) Nitrogen investigational allowances.—
2381
2382 Nitrogen Breakdown Investigational AllowancesPercent
2383
2384 Nitrate nitrogen 0.40
2385 Ammoniacal nitrogen 0.40
2386 Water soluble nitrogenor urea nitrogen 0.40
2387 Water insoluble nitrogen 0.30
2388
2389
2390 In no case may the investigational allowance exceed 50 percent
2391 of the amount guaranteed.
2392 (d) Secondary and micro plant nutrients, total or soluble.—
2393
2394 Element Investigational Allowances Percent
2395
2396 Calcium 0.2 unit + 5 percent of guarantee
2397 Magnesium 0.2 unit + 5 percent of guarantee
2398 Sulfur (free and combined)0.2 unit + 5 percent of guarantee
2399 Boron 0.003 unit + 15 percent of guarantee
2400 Cobalt 0.0001 unit + 30 percent of guarantee
2401 Chlorine 0.005 unit + 10 percent of guarantee
2402 Copper 0.005 unit + 10 percent of guarantee
2403 Iron 0.005 unit + 10 percent of guarantee
2404 Manganese 0.005 unit + 10 percent of guarantee
2405 Molybdenum 0.0001 unit + 30 percent of guarantee
2406 Sodium 0.005 unit + 10 percent of guarantee
2407 Zinc 0.005 unit + 10 percent of guarantee
2408
2409
2410 The maximum allowance for secondary and minor elements when
2411 calculated in accordance with this section is 1 unit (1
2412 percent). In no case, however, may the investigational allowance
2413 exceed 50 percent of the amount guaranteed.
2414 (e) Liming materials and gypsum.—
2415
2416 Range Percent Investigational AllowancesPercent
2417
2418 0-10 0.30
2419 Over 10-25 0.40
2420 Over 25 0.50
2421
2422 (f) Pesticides in fertilizer mixtures.—An investigational
2423 allowance of 25 percent of the guarantee shall be allowed on all
2424 pesticides when added to custom blend fertilizers.
2425 Reviser’s note.—The cited paragraphs, which relate to
2426 investigational allowances for fertilizer, were repealed
2427 pursuant to their own terms, effective July 1, 2014.
2428 Section 21. Section 624.351, Florida Statutes, is repealed.
2429 Reviser’s note.—The cited section, which relates to the Medicaid
2430 and Public Assistance Fraud Strike Force, was repealed
2431 pursuant to its own terms, effective June 30, 2014.
2432 Section 22. Section 624.352, Florida Statutes, is repealed.
2433 Reviser’s note.—The cited section, which relates to interagency
2434 agreements to detect and deter Medicaid and public
2435 assistance fraud, was repealed pursuant to its own terms,
2436 effective June 30, 2014.
2437 Section 23. Subsection (7) of section 626.2815, Florida
2438 Statutes, is repealed.
2439 Reviser’s note.—The cited subsection, which relates to a
2440 requirement that persons holding a license to solicit or
2441 sell life insurance must complete a minimum of 3 hours in
2442 continuing education on the subject of suitability in
2443 annuity and life insurance transactions, was deleted from
2444 s. 626.2815 by s. 11, ch. 2012-209, Laws of Florida,
2445 effective October 1, 2014. Since the subsection was not
2446 repealed by a “current session” of the Legislature, it may
2447 be omitted from the 2015 Florida Statutes only through a
2448 reviser’s bill duly enacted by the Legislature. See s.
2449 11.242(5)(b) and (i).
2450 Section 24. Paragraph (b) of subsection (4) of section
2451 828.27, Florida Statutes, is amended to read:
2452 828.27 Local animal control or cruelty ordinances;
2453 penalty.—
2454 (4)
2455 (b)1. The governing body of a county or municipality may
2456 impose and collect a surcharge of up to $5 upon each civil
2457 penalty imposed for violation of an ordinance relating to animal
2458 control or cruelty. The proceeds from such surcharges shall be
2459 used to pay the costs of training for animal control officers.
2460 2. In addition to the uses set forth in subparagraph 1., a
2461 county, as defined in s. 125.011, may use the proceeds specified
2462 in that subparagraph and any carryover or fund balance from such
2463 proceeds for animal shelter operating expenses. This
2464 subparagraph expires July 1, 2014.
2465 Reviser’s note.—Amended to delete subparagraph (4)(b)2., which
2466 expired pursuant to its own terms, effective July 1, 2014.
2467 Section 25. Paragraph (e) of subsection (9) of section
2468 1002.32, Florida Statutes, is amended to read:
2469 1002.32 Developmental research (laboratory) schools.—
2470 (9) FUNDING.—Funding for a lab school, including a charter
2471 lab school, shall be provided as follows:
2472 (e)1. Each lab school shall receive funds for capital
2473 improvement purposes in an amount determined as follows:
2474 multiply the maximum allowable nonvoted discretionary millage
2475 for capital improvements pursuant to s. 1011.71(2) by 96 percent
2476 of the current year’s taxable value for school purposes for the
2477 district in which each lab school is located; divide the result
2478 by the total full-time equivalent membership of the district;
2479 and multiply the result by the full-time equivalent membership
2480 of the lab school. The amount obtained shall be discretionary
2481 capital improvement funds and shall be appropriated from state
2482 funds in the General Appropriations Act to the Lab School
2483 Educational Facility Trust Fund.
2484 2. Notwithstanding the provisions of subparagraph 1., for
2485 the 2013-2014 fiscal year, funds appropriated for capital
2486 improvement purposes shall be divided between lab schools based
2487 on full-time equivalent student membership. This subparagraph
2488 expires July 1, 2014.
2489 Reviser’s note.—Amended to delete subparagraph (9)(e)2., which
2490 expired pursuant to its own terms, effective July 1, 2014.
2491 Section 26. Subsection (4) of section 409.91195, Florida
2492 Statutes, is amended to read:
2493 409.91195 Medicaid Pharmaceutical and Therapeutics
2494 Committee.—There is created a Medicaid Pharmaceutical and
2495 Therapeutics Committee within the agency for the purpose of
2496 developing a Medicaid preferred drug list.
2497 (4) Upon recommendation of the committee, the agency shall
2498 adopt a preferred drug list as described in s. 409.912(8)
2499 409.912(37). To the extent feasible, the committee shall review
2500 all drug classes included on the preferred drug list every 12
2501 months, and may recommend additions to and deletions from the
2502 preferred drug list, such that the preferred drug list provides
2503 for medically appropriate drug therapies for Medicaid patients
2504 which achieve cost savings contained in the General
2505 Appropriations Act.
2506 Reviser’s note.—Amended to conform to the redesignation of
2507 subunits of s. 409.912 by this act.
2508 Section 27. Subsection (1) of section 409.91196, Florida
2509 Statutes, is amended to read:
2510 409.91196 Supplemental rebate agreements; public records
2511 and public meetings exemption.—
2512 (1) The rebate amount, percent of rebate, manufacturer’s
2513 pricing, and supplemental rebate, and other trade secrets as
2514 defined in s. 688.002 that the agency has identified for use in
2515 negotiations, held by the Agency for Health Care Administration
2516 under s. 409.912(8)(a)7. 409.912(37)(a)7. are confidential and
2517 exempt from s. 119.07(1) and s. 24(a), Art. I of the State
2518 Constitution.
2519 Reviser’s note.—Amended to conform to the redesignation of
2520 subunits of s. 409.912 by this act.
2521 Section 28. Subsections (1), (6), (12), and (13) of section
2522 409.962, Florida Statutes, are amended to read:
2523 409.962 Definitions.—As used in this part, except as
2524 otherwise specifically provided, the term:
2525 (1) “Accountable care organization” means an entity
2526 qualified as an accountable care organization in accordance with
2527 federal regulations, and which meets the requirements of a
2528 provider service network as described in s. 409.912(2)
2529 409.912(4)(d).
2530 (6) “Eligible plan” means a health insurer authorized under
2531 chapter 624, an exclusive provider organization authorized under
2532 chapter 627, a health maintenance organization authorized under
2533 chapter 641, or a provider service network authorized under s.
2534 409.912(2) 409.912(4)(d) or an accountable care organization
2535 authorized under federal law. For purposes of the managed
2536 medical assistance program, the term also includes the
2537 Children’s Medical Services Network authorized under chapter 391
2538 and entities qualified under 42 C.F.R. part 422 as Medicare
2539 Advantage Preferred Provider Organizations, Medicare Advantage
2540 Provider-sponsored Organizations, Medicare Advantage Health
2541 Maintenance Organizations, Medicare Advantage Coordinated Care
2542 Plans, and Medicare Advantage Special Needs Plans, and the
2543 Program of All-inclusive Care for the Elderly.
2544 (12) “Prepaid plan” means a managed care plan that is
2545 licensed or certified as a risk-bearing entity, or qualified
2546 pursuant to s. 409.912(2) 409.912(4)(d), in the state and is
2547 paid a prospective per-member, per-month payment by the agency.
2548 (13) “Provider service network” means an entity qualified
2549 pursuant to s. 409.912(2) 409.912(4)(d) of which a controlling
2550 interest is owned by a health care provider, or group of
2551 affiliated providers, or a public agency or entity that delivers
2552 health services. Health care providers include Florida-licensed
2553 health care professionals or licensed health care facilities,
2554 federally qualified health care centers, and home health care
2555 agencies.
2556 Reviser’s note.—Amended to conform to the redesignation of
2557 subunits of s. 409.912 by this act.
2558 Section 29. Section 636.0145, Florida Statutes, is amended
2559 to read:
2560 636.0145 Certain entities contracting with Medicaid.
2561 Notwithstanding the requirements of s. 409.912(4)(b), An entity
2562 that is providing comprehensive inpatient and outpatient mental
2563 health care services to certain Medicaid recipients in
2564 Hillsborough, Highlands, Hardee, Manatee, and Polk Counties
2565 through a capitated, prepaid arrangement pursuant to the federal
2566 waiver provided for in s. 409.905(5) must become licensed under
2567 this chapter by December 31, 1998. Any entity licensed under
2568 this chapter which provides services solely to Medicaid
2569 recipients under a contract with Medicaid is exempt from ss.
2570 636.017, 636.018, 636.022, 636.028, 636.034, and 636.066(1).
2571 Reviser’s note.—Amended to conform to the deletion of s.
2572 409.912(4)(b) by this act to conform to its expiration
2573 pursuant to its own terms, effective October 1, 2014.
2574 Section 30. Subsection (22) of section 641.19, Florida
2575 Statutes, is amended to read:
2576 641.19 Definitions.—As used in this part, the term:
2577 (22) “Provider service network” means a network authorized
2578 under s. 409.912(2) 409.912(4)(d), reimbursed on a prepaid
2579 basis, operated by a health care provider or group of affiliated
2580 health care providers, and which directly provides health care
2581 services under a Medicare, Medicaid, or Healthy Kids contract.
2582 Reviser’s note.—Amended to conform to the redesignation of
2583 subunits of s. 409.912 by this act.
2584 Section 31. Subsection (3) of section 641.225, Florida
2585 Statutes, is amended to read:
2586 641.225 Surplus requirements.—
2587 (3)(a) An entity providing prepaid capitated services which
2588 is authorized under s. 409.912(4)(a) and which applies for a
2589 certificate of authority is subject to the minimum surplus
2590 requirements set forth in subsection (1), unless the entity is
2591 backed by the full faith and credit of the county in which it is
2592 located.
2593 (b) An entity providing prepaid capitated services which is
2594 authorized under s. 409.912(4)(b) or (c), and which applies for
2595 a certificate of authority is subject to the minimum surplus
2596 requirements set forth in s. 409.912.
2597 Reviser’s note.—Amended to conform to the expiration of
2598 paragraphs (4)(a)-(c) of s. 409.912 pursuant to their own
2599 terms, effective October 1, 2014, and confirmation of the
2600 expiration by this act.
2601 Section 32. Subsection (4) of section 641.386, Florida
2602 Statutes, is amended to read:
2603 641.386 Agent licensing and appointment required;
2604 exceptions.—
2605 (4) All agents and health maintenance organizations shall
2606 comply with and be subject to the applicable provisions of ss.
2607 641.309 and 409.912(5) 409.912(20), and all companies and
2608 entities appointing agents shall comply with s. 626.451, when
2609 marketing for any health maintenance organization licensed
2610 pursuant to this part, including those organizations under
2611 contract with the Agency for Health Care Administration to
2612 provide health care services to Medicaid recipients or any
2613 private entity providing health care services to Medicaid
2614 recipients pursuant to a prepaid health plan contract with the
2615 Agency for Health Care Administration.
2616 Reviser’s note.—Amended to conform to the redesignation of
2617 subunits of s. 409.912 by this act.
2618 Section 33. This act shall take effect on the 60th day
2619 after adjournment sine die of the session of the Legislature in
2620 which enacted.