Bill Amendment: FL S1292 | 2021 | Regular Session
NOTE: For additional amemendments please see the Bill Drafting List
Bill Title: Medicaid
Status: 2021-04-26 - Laid on Table, companion bill(s) passed, see CS/HB 1057 (Ch. 2021-151) [S1292 Detail]
Download: Florida-2021-S1292-Senate_Committee_Amendment_385204.html
Bill Title: Medicaid
Status: 2021-04-26 - Laid on Table, companion bill(s) passed, see CS/HB 1057 (Ch. 2021-151) [S1292 Detail]
Download: Florida-2021-S1292-Senate_Committee_Amendment_385204.html
Florida Senate - 2021 COMMITTEE AMENDMENT Bill No. SB 1292 Ì385204~Î385204 LEGISLATIVE ACTION Senate . House . . . . . ————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————— The Committee on Health Policy (Bean) recommended the following: 1 Senate Amendment (with directory and title amendments) 2 3 Delete lines 101 - 741 4 and insert: 5 (14) A provider of prescribed drugs shall be reimbursed in 6 an amount not to exceed the lesser of the actual acquisition 7 cost based on the Centers for Medicare and Medicaid Services 8 National Average Drug Acquisition Cost pricing files plus a 9 professional dispensing fee, the wholesale acquisition cost plus 10 a professional dispensing fee, the state maximum allowable cost 11 plus a professional dispensing fee, or the usual and customary 12 charge billed by the providerthe least of the amount billed by13the provider, the provider’s usual and customary charge, or the14Medicaid maximum allowable fee established by the agency, plus a15dispensing fee. The Medicaid maximum allowable fee for16ingredient cost must be based on the lowest of: the average17wholesale price (AWP) minus 16.4 percent, the wholesaler18acquisition cost (WAC) plus 1.5 percent, the federal upper limit19(FUL), the state maximum allowable cost (SMAC), or the usual and20customary (UAC) charge billed by the provider. 21 (a) Medicaid providers must dispense generic drugs if 22 available at lower cost and the agency has not determined that 23 the branded product is more cost-effective, unless the 24 prescriber has requested and received approval to require the 25 branded product. 26 (b)The agency shall implement a variable dispensing fee27for prescribed medicines while ensuring continued access for28Medicaid recipients. The variable dispensing fee may be based29upon, but not limited to, either or both the volume of30prescriptions dispensed by a specific pharmacy provider, the31volume of prescriptions dispensed to an individual recipient,32and dispensing of preferred-drug-list products.33(c) The agency may increase the pharmacy dispensing fee34authorized by statute and in the General Appropriations Act by35$0.50 for the dispensing of a Medicaid preferred-drug-list36product and reduce the pharmacy dispensing fee by $0.50 for the37dispensing of a Medicaid product that is not included on the38preferred drug list.39(d)The agency may establish a supplemental pharmaceutical 40 dispensing fee to be paid to providers returning unused unit 41 dose packaged medications to stock and crediting the Medicaid 42 program for the ingredient cost of those medications if the 43 ingredient costs to be credited exceed the value of the 44 supplemental dispensing fee. 45 (c)(e)The agency may limit reimbursement for prescribed 46 medicine in order to comply with any limitations or directions 47 provided in the General Appropriations Act, which may include 48 implementing a prospective or concurrent utilization review 49 program. 50 Section 4. Subsections (9) and (11) of section 409.91195, 51 Florida Statutes, are amended, and subsection (4) of that 52 section is reenacted for the purpose of incorporating the 53 amendment made by this act to section 409.912, Florida Statutes, 54 in a reference thereto, to read: 55 409.91195 Medicaid Pharmaceutical and Therapeutics 56 Committee.—There is created a Medicaid Pharmaceutical and 57 Therapeutics Committee within the agency for the purpose of 58 developing a Medicaid preferred drug list. 59 (4) Upon recommendation of the committee, the agency shall 60 adopt a preferred drug list as described in s. 409.912(5). To 61 the extent feasible, the committee shall review all drug classes 62 included on the preferred drug list every 12 months, and may 63 recommend additions to and deletions from the preferred drug 64 list, such that the preferred drug list provides for medically 65 appropriate drug therapies for Medicaid patients which achieve 66 cost savings contained in the General Appropriations Act. 67(9) Upon timely notice, the agency shall ensure that any68therapeutic class of drugs which includes a drug that has been69removed from distribution to the public by its manufacturer or70the United States Food and Drug Administration or has been71required to carry a black box warning label by the United States72Food and Drug Administration because of safety concerns is73reviewed by the committee at the next regularly scheduled74meeting. After such review, the committee must recommend whether75to retain the therapeutic class of drugs or subcategories of76drugs within a therapeutic class on the preferred drug list and77whether to institute prior authorization requirements necessary78to ensure patient safety.79 (10)(11)Medicaid recipients may appeal agency preferred 80 drug formulary decisions using the Medicaid fair hearing process 81 administered by the Agency for Health Care Administration 82Department of Children and Families. 83 Section 5. Paragraphs (a) and (c) of subsection (5) of 84 section 409.912, Florida Statutes, are amended to read: 85 409.912 Cost-effective purchasing of health care.—The 86 agency shall purchase goods and services for Medicaid recipients 87 in the most cost-effective manner consistent with the delivery 88 of quality medical care. To ensure that medical services are 89 effectively utilized, the agency may, in any case, require a 90 confirmation or second physician’s opinion of the correct 91 diagnosis for purposes of authorizing future services under the 92 Medicaid program. This section does not restrict access to 93 emergency services or poststabilization care services as defined 94 in 42 C.F.R. s. 438.114. Such confirmation or second opinion 95 shall be rendered in a manner approved by the agency. The agency 96 shall maximize the use of prepaid per capita and prepaid 97 aggregate fixed-sum basis services when appropriate and other 98 alternative service delivery and reimbursement methodologies, 99 including competitive bidding pursuant to s. 287.057, designed 100 to facilitate the cost-effective purchase of a case-managed 101 continuum of care. The agency shall also require providers to 102 minimize the exposure of recipients to the need for acute 103 inpatient, custodial, and other institutional care and the 104 inappropriate or unnecessary use of high-cost services. The 105 agency shall contract with a vendor to monitor and evaluate the 106 clinical practice patterns of providers in order to identify 107 trends that are outside the normal practice patterns of a 108 provider’s professional peers or the national guidelines of a 109 provider’s professional association. The vendor must be able to 110 provide information and counseling to a provider whose practice 111 patterns are outside the norms, in consultation with the agency, 112 to improve patient care and reduce inappropriate utilization. 113 The agency may mandate prior authorization, drug therapy 114 management, or disease management participation for certain 115 populations of Medicaid beneficiaries, certain drug classes, or 116 particular drugs to prevent fraud, abuse, overuse, and possible 117 dangerous drug interactions. The Pharmaceutical and Therapeutics 118 Committee shall make recommendations to the agency on drugs for 119 which prior authorization is required. The agency shall inform 120 the Pharmaceutical and Therapeutics Committee of its decisions 121 regarding drugs subject to prior authorization. The agency is 122 authorized to limit the entities it contracts with or enrolls as 123 Medicaid providers by developing a provider network through 124 provider credentialing. The agency may competitively bid single 125 source-provider contracts if procurement of goods or services 126 results in demonstrated cost savings to the state without 127 limiting access to care. The agency may limit its network based 128 on the assessment of beneficiary access to care, provider 129 availability, provider quality standards, time and distance 130 standards for access to care, the cultural competence of the 131 provider network, demographic characteristics of Medicaid 132 beneficiaries, practice and provider-to-beneficiary standards, 133 appointment wait times, beneficiary use of services, provider 134 turnover, provider profiling, provider licensure history, 135 previous program integrity investigations and findings, peer 136 review, provider Medicaid policy and billing compliance records, 137 clinical and medical record audits, and other factors. Providers 138 are not entitled to enrollment in the Medicaid provider network. 139 The agency shall determine instances in which allowing Medicaid 140 beneficiaries to purchase durable medical equipment and other 141 goods is less expensive to the Medicaid program than long-term 142 rental of the equipment or goods. The agency may establish rules 143 to facilitate purchases in lieu of long-term rentals in order to 144 protect against fraud and abuse in the Medicaid program as 145 defined in s. 409.913. The agency may seek federal waivers 146 necessary to administer these policies. 147 (5)(a) The agency shall implement a Medicaid prescribed 148 drug spending-control program that includes the following 149 components: 150 1. A Medicaid preferred drug list, which shall be a listing 151 of cost-effective therapeutic options recommended by the 152 Medicaid Pharmacy and Therapeutics Committee established 153 pursuant to s. 409.91195 and adopted by the agency for each 154 therapeutic class on the preferred drug list. At the discretion 155 of the committee, and when feasible, the preferred drug list 156 should include at least two products in a therapeutic class. The 157 agency may post the preferred drug list and updates to the list 158 on an Internet website without following the rulemaking 159 procedures of chapter 120. Antiretroviral agents are excluded 160 from the preferred drug list. The agency shall also limit the 161 amount of a prescribed drug dispensed to no more than a 34-day 162 supply unless the drug products’ smallest marketed package is 163 greater than a 34-day supply, or the drug is determined by the 164 agency to be a maintenance drug in which case a 100-day maximum 165 supply may be authorized. The agency may seek any federal 166 waivers necessary to implement these cost-control programs and 167 to continue participation in the federal Medicaid rebate 168 program, or alternatively to negotiate state-only manufacturer 169 rebates. The agency may adopt rules to administer this 170 subparagraph. The agency shall continue to provide unlimited 171 contraceptive drugs and items. The agency must establish 172 procedures to ensure that: 173 a. There is a response to a request for prior authorization 174consultationby telephone or other telecommunication device 175 within 24 hours after receipt of a request for prior 176 authorizationconsultation; and 177 b. A 72-hour supply of the drug prescribed is provided in 178 an emergency or when the agency does not provide a response 179 within 24 hours as required by sub-subparagraph a. 180 2. A provider of prescribed drugs is reimbursed in an 181 amount not to exceed the lesser of the actual acquisition cost 182 based on the Centers for Medicare and Medicaid Services National 183 Average Drug Acquisition Cost pricing files plus a professional 184 dispensing fee, the wholesale acquisition cost plus a 185 professional dispensing fee, the state maximum allowable cost 186 plus a professional dispensing fee, or the usual and customary 187 charge billed by the providerReimbursement to pharmacies for188Medicaid prescribed drugs shall be set at the lowest of: the189average wholesale price (AWP) minus 16.4 percent, the wholesaler190acquisition cost (WAC) plus 1.5 percent, the federal upper limit191(FUL), the state maximum allowable cost (SMAC), or the usual and192customary (UAC) charge billed by the provider. 193 3. The agency shall develop and implement a process for 194 managing the drug therapies of Medicaid recipients who are using 195 significant numbers of prescribed drugs each month. The 196 management process may include, but is not limited to, 197 comprehensive, physician-directed medical-record reviews, claims 198 analyses, and case evaluations to determine the medical 199 necessity and appropriateness of a patient’s treatment plan and 200 drug therapies. The agency may contract with a private 201 organization to provide drug-program-management services. The 202 Medicaid drug benefit management program shall include 203 initiatives to manage drug therapies for HIV/AIDS patients, 204 patients using 20 or more unique prescriptions in a 180-day 205 period, and the top 1,000 patients in annual spending. The 206 agency shall enroll any Medicaid recipient in the drug benefit 207 management program if he or she meets the specifications of this 208 provision and is not enrolled in a Medicaid health maintenance 209 organization. 210 4. The agency may limit the size of its pharmacy network 211 based on need, competitive bidding, price negotiations, 212 credentialing, or similar criteria. The agency shall give 213 special consideration to rural areas in determining the size and 214 location of pharmacies included in the Medicaid pharmacy 215 network. A pharmacy credentialing process may include criteria 216 such as a pharmacy’s full-service status, location, size, 217 patient educational programs, patient consultation, disease 218 management services, and other characteristics. The agency may 219 impose a moratorium on Medicaid pharmacy enrollment if it is 220 determined that it has a sufficient number of Medicaid 221 participating providers. The agency must allow dispensing 222 practitioners to participate as a part of the Medicaid pharmacy 223 network regardless of the practitioner’s proximity to any other 224 entity that is dispensing prescription drugs under the Medicaid 225 program. A dispensing practitioner must meet all credentialing 226 requirements applicable to his or her practice, as determined by 227 the agency. 228 5. The agency shall develop and implement a program that 229 requires Medicaid practitioners who issue written prescriptions 230 for medicinal drugs to use a counterfeit-proof prescription pad 231 for Medicaid prescriptions. The agency shall require the use of 232 standardized counterfeit-proof prescription pads by prescribers 233 who issue written prescriptions for Medicaid recipients. The 234 agency may implement the program in targeted geographic areas or 235 statewide. 236 6. The agency may enter into arrangements that require 237 manufacturers of generic drugs prescribed to Medicaid recipients 238 to provide rebates of at least 15.1 percent of the average 239 manufacturer price for the manufacturer’s generic products. 240 These arrangements shall require that if a generic-drug 241 manufacturer pays federal rebates for Medicaid-reimbursed drugs 242 at a level below 15.1 percent, the manufacturer must provide a 243 supplemental rebate to the state in an amount necessary to 244 achieve a 15.1-percent rebate level. 245 7. The agency may establish a preferred drug list as 246 described in this subsection, and, pursuant to the establishment 247 of such preferred drug list, negotiate supplemental rebates from 248 manufacturers that are in addition to those required by Title 249 XIX of the Social Security Act and at no less than 14 percent of 250 the average manufacturer price as defined in 42 U.S.C. s. 1936 251 on the last day of a quarter unless the federal or supplemental 252 rebate, or both, equals or exceeds 29 percent. There is no upper 253 limit on the supplemental rebates the agency may negotiate. The 254 agency may determine that specific products, brand-name or 255 generic, are competitive at lower rebate percentages. Agreement 256 to pay the minimum supplemental rebate percentage guarantees a 257 manufacturer that the Medicaid Pharmaceutical and Therapeutics 258 Committee will consider a product for inclusion on the preferred 259 drug list. However, a pharmaceutical manufacturer is not 260 guaranteed placement on the preferred drug list by simply paying 261 the minimum supplemental rebate. Agency decisions will be made 262 on the clinical efficacy of a drug and recommendations of the 263 Medicaid Pharmaceutical and Therapeutics Committee, as well as 264 the price of competing products minus federal and state rebates. 265 The agency may contract with an outside agency or contractor to 266 conduct negotiations for supplemental rebates. For the purposes 267 of this section, the term “supplemental rebates” means cash 268 rebates. Value-added programs as a substitution for supplemental 269 rebates are prohibited. The agency may seek any federal waivers 270 to implement this initiative. 271 8.a.The agency shall expand home delivery of pharmacy272products. The agency may amend the state plan and issue a273procurement, as necessary, in order to implement this program.274The procurements must include agreements with a pharmacy or275pharmacies located in the state to provide mail order delivery276services at no cost to the recipients who elect to receive home277delivery of pharmacy products. The procurement must focus on278serving recipients with chronic diseases for which pharmacy279expenditures represent a significant portion of Medicaid280pharmacy expenditures or which impact a significant portion of281the Medicaid population. The agency may seek and implement any282federal waivers necessary to implement this subparagraph.2839. The agency shall limit to one dose per month any drug284prescribed to treat erectile dysfunction.28510.a.The agency may implement a Medicaid behavioral drug 286 management system. The agency may contract with a vendor that 287 has experience in operating behavioral drug management systems 288 to implement this program. The agency may seek federal waivers 289 to implement this program. 290 b. The agency, in conjunction with the Department of 291 Children and Families, may implement the Medicaid behavioral 292 drug management system that is designed to improve the quality 293 of care and behavioral health prescribing practices based on 294 best practice guidelines, improve patient adherence to 295 medication plans, reduce clinical risk, and lower prescribed 296 drug costs and the rate of inappropriate spending on Medicaid 297 behavioral drugs. The program may include the following 298 elements: 299 (I) Provide for the development and adoption of best 300 practice guidelines for behavioral health-related drugs such as 301 antipsychotics, antidepressants, and medications for treating 302 bipolar disorders and other behavioral conditions; translate 303 them into practice; review behavioral health prescribers and 304 compare their prescribing patterns to a number of indicators 305 that are based on national standards; and determine deviations 306 from best practice guidelines. 307 (II) Implement processes for providing feedback to and 308 educating prescribers using best practice educational materials 309 and peer-to-peer consultation. 310 (III) Assess Medicaid beneficiaries who are outliers in 311 their use of behavioral health drugs with regard to the numbers 312 and types of drugs taken, drug dosages, combination drug 313 therapies, and other indicators of improper use of behavioral 314 health drugs. 315 (IV) Alert prescribers to patients who fail to refill 316 prescriptions in a timely fashion, are prescribed multiple same 317 class behavioral health drugs, and may have other potential 318 medication problems. 319 (V) Track spending trends for behavioral health drugs and 320 deviation from best practice guidelines. 321 (VI) Use educational and technological approaches to 322 promote best practices, educate consumers, and train prescribers 323 in the use of practice guidelines. 324 (VII) Disseminate electronic and published materials. 325 (VIII) Hold statewide and regional conferences. 326 (IX) Implement a disease management program with a model 327 quality-based medication component for severely mentally ill 328 individuals and emotionally disturbed children who are high 329 users of care. 330 9.11.The agency shall implement a Medicaid prescription 331 drug management system. 332 a. The agency may contract with a vendor that has 333 experience in operating prescription drug management systems in 334 order to implement this system. Any management system that is 335 implemented in accordance with this subparagraph must rely on 336 cooperation between physicians and pharmacists to determine 337 appropriate practice patterns and clinical guidelines to improve 338 the prescribing, dispensing, and use of drugs in the Medicaid 339 program. The agency may seek federal waivers to implement this 340 program. 341 b. The drug management system must be designed to improve 342 the quality of care and prescribing practices based on best 343 practice guidelines, improve patient adherence to medication 344 plans, reduce clinical risk, and lower prescribed drug costs and 345 the rate of inappropriate spending on Medicaid prescription 346 drugs. The program must: 347 (I) Provide for the adoption of best practice guidelines 348 for the prescribing and use of drugs in the Medicaid program, 349 including translating best practice guidelines into practice; 350 reviewing prescriber patterns and comparing them to indicators 351 that are based on national standards and practice patterns of 352 clinical peers in their community, statewide, and nationally; 353 and determine deviations from best practice guidelines. 354 (II) Implement processes for providing feedback to and 355 educating prescribers using best practice educational materials 356 and peer-to-peer consultation. 357 (III) Assess Medicaid recipients who are outliers in their 358 use of a single or multiple prescription drugs with regard to 359 the numbers and types of drugs taken, drug dosages, combination 360 drug therapies, and other indicators of improper use of 361 prescription drugs. 362 (IV) Alert prescribers to recipients who fail to refill 363 prescriptions in a timely fashion, are prescribed multiple drugs 364 that may be redundant or contraindicated, or may have other 365 potential medication problems. 366 10.12.The agency may contract for drug rebate 367 administration, including, but not limited to, calculating 368 rebate amounts, invoicing manufacturers, negotiating disputes 369 with manufacturers, and maintaining a database of rebate 370 collections. 371 11.13.The agency may specify the preferred daily dosing 372 form or strength for the purpose of promoting best practices 373 with regard to the prescribing of certain drugs as specified in 374 the General Appropriations Act and ensuring cost-effective 375 prescribing practices. 376 12.14.The agency may require prior authorization for 377 Medicaid-covered prescribed drugs. The agency may prior 378 authorize the use of a product: 379 a. For an indication not approved in labeling; 380 b. To comply with certain clinical guidelines; or 381 c. If the product has the potential for overuse, misuse, or 382 abuse. 383 384 The agency may require the prescribing professional to provide 385 information about the rationale and supporting medical evidence 386 for the use of a drug. The agency shall post prior 387 authorization, step-edit criteria and protocol, and updates to 388 the list of drugs that are subject to prior authorization on the 389 agency’s Internet website within 21 days after the prior 390 authorization and step-edit criteria and protocol and updates 391 are approved by the agency. For purposes of this subparagraph, 392 the term “step-edit” means an automatic electronic review of 393 certain medications subject to prior authorization. 394 13.15.The agency, in conjunction with the Pharmaceutical 395 and Therapeutics Committee, may require age-related prior 396 authorizations for certain prescribed drugs. The agency may 397 preauthorize the use of a drug for a recipient who may not meet 398 the age requirement or may exceed the length of therapy for use 399 of this product as recommended by the manufacturer and approved 400 by the Food and Drug Administration. Prior authorization may 401 require the prescribing professional to provide information 402 about the rationale and supporting medical evidence for the use 403 of a drug. 404 14.16.The agency shall implement a step-therapy prior 405 authorization approval process for medications excluded from the 406 preferred drug list. Medications listed on the preferred drug 407 list must be used within the previous 12 months before the 408 alternative medications that are not listed. The step-therapy 409 prior authorization may require the prescriber to use the 410 medications of a similar drug class or for a similar medical 411 indication unless contraindicated in the Food and Drug 412 Administration labeling. The trial period between the specified 413 steps may vary according to the medical indication. The step 414 therapy approval process shall be developed in accordance with 415 the committee as stated in s. 409.91195(7) and (8). A drug 416 product may be approved without meeting the step-therapy prior 417 authorization criteria if the prescribing physician provides the 418 agency with additional written medical or clinical documentation 419 that the product is medically necessary because: 420 a. There is not a drug on the preferred drug list to treat 421 the disease or medical condition which is an acceptable clinical 422 alternative; 423 b. The alternatives have been ineffective in the treatment 424 of the beneficiary’s disease; or 425 c. Based on historic evidence and known characteristics of 426 the patient and the drug, the drug is likely to be ineffective, 427 or the number of doses have been ineffective. 428 429 The agency shall work with the physician to determine the best 430 alternative for the patient. The agency may adopt rules waiving 431 the requirements for written clinical documentation for specific 432 drugs in limited clinical situations. 433 15.17.The agency shall implement a return and reuse 434 program for drugs dispensed by pharmacies to institutional 435 recipients, which includes payment of a $5 restocking fee for 436 the implementation and operation of the program. The return and 437 reuse program shall be implemented electronically and in a 438 manner that promotes efficiency. The program must permit a 439 pharmacy to exclude drugs from the program if it is not 440 practical or cost-effective for the drug to be included and must 441 provide for the return to inventory of drugs that cannot be 442 credited or returned in a cost-effective manner. The agency 443 shall determine if the program has reduced the amount of 444 Medicaid prescription drugs which are destroyed on an annual 445 basis and if there are additional ways to ensure more 446 prescription drugs are not destroyed which could safely be 447 reused. 448(c) The agency shall submit quarterly reports to the449Governor, the President of the Senate, and the Speaker of the450House of Representatives which must include, but need not be451limited to, the progress made in implementing this subsection452and its effect on Medicaid prescribed-drug expenditures.453 Section 6. Section 409.91213, Florida Statutes, is 454 repealed. 455 Section 7. Paragraph (d) of subsection (1) of section 456 409.913, Florida Statutes, is amended to read: 457 409.913 Oversight of the integrity of the Medicaid 458 program.—The agency shall operate a program to oversee the 459 activities of Florida Medicaid recipients, and providers and 460 their representatives, to ensure that fraudulent and abusive 461 behavior and neglect of recipients occur to the minimum extent 462 possible, and to recover overpayments and impose sanctions as 463 appropriate. Each January 15, the agency and the Medicaid Fraud 464 Control Unit of the Department of Legal Affairs shall submit a 465 report to the Legislature documenting the effectiveness of the 466 state’s efforts to control Medicaid fraud and abuse and to 467 recover Medicaid overpayments during the previous fiscal year. 468 The report must describe the number of cases opened and 469 investigated each year; the sources of the cases opened; the 470 disposition of the cases closed each year; the amount of 471 overpayments alleged in preliminary and final audit letters; the 472 number and amount of fines or penalties imposed; any reductions 473 in overpayment amounts negotiated in settlement agreements or by 474 other means; the amount of final agency determinations of 475 overpayments; the amount deducted from federal claiming as a 476 result of overpayments; the amount of overpayments recovered 477 each year; the amount of cost of investigation recovered each 478 year; the average length of time to collect from the time the 479 case was opened until the overpayment is paid in full; the 480 amount determined as uncollectible and the portion of the 481 uncollectible amount subsequently reclaimed from the Federal 482 Government; the number of providers, by type, that are 483 terminated from participation in the Medicaid program as a 484 result of fraud and abuse; and all costs associated with 485 discovering and prosecuting cases of Medicaid overpayments and 486 making recoveries in such cases. The report must also document 487 actions taken to prevent overpayments and the number of 488 providers prevented from enrolling in or reenrolling in the 489 Medicaid program as a result of documented Medicaid fraud and 490 abuse and must include policy recommendations necessary to 491 prevent or recover overpayments and changes necessary to prevent 492 and detect Medicaid fraud. All policy recommendations in the 493 report must include a detailed fiscal analysis, including, but 494 not limited to, implementation costs, estimated savings to the 495 Medicaid program, and the return on investment. The agency must 496 submit the policy recommendations and fiscal analyses in the 497 report to the appropriate estimating conference, pursuant to s. 498 216.137, by February 15 of each year. The agency and the 499 Medicaid Fraud Control Unit of the Department of Legal Affairs 500 each must include detailed unit-specific performance standards, 501 benchmarks, and metrics in the report, including projected cost 502 savings to the state Medicaid program during the following 503 fiscal year. 504 (1) For the purposes of this section, the term: 505 (d) “Medical necessity” or “medically necessary” means any 506 goods or services necessary to palliate the effects of a 507 terminal condition, or to prevent, diagnose, correct, cure, 508 alleviate, or preclude deterioration of a condition that 509 threatens life, causes pain or suffering, or results in illness 510 or infirmity, which goods or services are provided in accordance 511 with generally accepted standards of medical practice. For 512 purposes of determining Medicaid reimbursement, the agency is 513 the final arbiter of medical necessity. Determinations of 514 medical necessity must be made by a licensed physician employed 515 by or under contract with the agency, except for behavior 516 analysis services, which may be determined by a licensed 517 physician or a doctoral-level board-certified behavior analyst. 518 Determinationsandmust be based upon information available at 519 the time the goods or services are requestedprovided. 520 521 ====== D I R E C T O R Y C L A U S E A M E N D M E N T ====== 522 And the directory clause is amended as follows: 523 Delete lines 71 - 72 524 and insert: 525 Section 3. Subsection (14) of section 409.908, Florida 526 Statutes, is amended to read: 527 528 ================= T I T L E A M E N D M E N T ================ 529 And the title is amended as follows: 530 Delete lines 8 - 38 531 and insert: 532 amending s. 409.908, F.S.; revising the method for 533 determining prescribed drug provider reimbursements; 534 deleting a requirement for the agency to implement 535 certain fees for prescribed medicines; deleting 536 authorization for the agency to increase certain 537 dispensing fees by certain amounts; reenacting and 538 amending s. 409.91195, F.S., relating to the Medicaid 539 Pharmaceutical and Therapeutics Committee; deleting a 540 requirement for the agency to ensure that the 541 committee reviews certain drugs under certain 542 circumstances; designating the agency, rather than the 543 Department of Children and Families, as the 544 administrator for certain hearings; amending s. 545 409.912, F.S.; requiring the agency to establish 546 certain procedures related to prior authorization 547 requests rather than prior consultation requests; 548 revising the method for determining prescribed drug 549 provider reimbursements; deleting a requirement for 550 the agency to expand home delivery of pharmacy 551 products; deleting a dosage limitation on certain 552 drugs; deleting a requirement for the agency to submit 553 certain quarterly reports to the Governor and the 554 Legislature; repealing s. 409.91213, F.S., relating to 555 quarterly progress reports and annual reports; 556 amending s. 409.913, F.S.; revising the definitions of 557 the terms “medical necessity” and “medically 558 necessary” to provide an exception for behavior 559 analysis services determinations; requiring that 560 determinations be based on information available at 561 the time goods or services are requested, rather than 562 at the time such goods or services are provided; 563 repealing s. 765.53, F.S., relating to the