Bill Text: FL S1484 | 2010 | Regular Session | Enrolled

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Bill Title: Medicaid [WPSC]

Spectrum: Partisan Bill (Republican 1-0)

Status: (Passed) 2010-05-28 - Approved by Governor; Chapter No. 2010-144 [S1484 Detail]

Download: Florida-2010-S1484-Enrolled.html

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ENROLLED 
2010 Legislature            CS for CS for SB 1484, 2nd Engrossed 
20101484er 
1 
2         An act relating to Medicaid; requiring that the Agency 
3         for Health Care Administration request an extension of 
4         a specified federal waiver; requiring the agency to 
5         report each month to the Legislature; requiring that 
6         certain changes of terms and conditions relating to 
7         the low-income pool be approved by the Legislative 
8         Budget Commission; requiring that the agency develop a 
9         methodology for intergovernmental transfers in any 
10         expansion of prepaid managed care in the Medicaid 
11         program; requiring that the secretary appoint a 
12         technical advisory panel; requiring a report to the 
13         Governor and Legislature; creating s. 624.35, F.S.; 
14         providing a short title; creating s. 624.351, F.S.; 
15         providing legislative findings; establishing the 
16         Medicaid and Public Assistance Fraud Strike Force 
17         within the Department of Financial Services to 
18         coordinate efforts to eliminate Medicaid and public 
19         assistance fraud; providing for membership; providing 
20         for meetings; specifying duties; requiring an annual 
21         report to the Legislature and Governor; creating s. 
22         624.352, F.S.; directing the Chief Financial Officer 
23         to prepare model interagency agreements that address 
24         Medicaid and public assistance fraud; specifying which 
25         agencies may be a party to such agreements; amending 
26         s. 16.59, F.S.; conforming provisions to changes made 
27         by the act; requiring the Divisions of Insurance Fraud 
28         and Public Assistance Fraud in the Department of 
29         Financial Services to be collocated with the Medicaid 
30         Fraud Control Unit if possible; requiring positions 
31         dedicated to Medicaid managed care fraud to be 
32         collocated with the Division of Insurance Fraud; 
33         amending s. 20.121, F.S.; establishing the Division of 
34         Public Assistance Fraud within the Department of 
35         Financial Services; amending ss. 411.01, 414.33, and 
36         414.39, F.S.; conforming provisions to changes made by 
37         the act; transferring, renumbering, and amending s. 
38         943.401, F.S.; directing the Department of Financial 
39         Services rather than the Department of Law Enforcement 
40         to investigate public assistance fraud; creating s. 
41         409.91212, F.S.; requiring that each managed care plan 
42         adopt an anti-fraud plan; specifying requirements for 
43         the plan; requiring that a managed care plan providing 
44         Medicaid services to establish and maintain a fraud 
45         investigative unit or contract for such services; 
46         providing requirements for reports to the Office of 
47         Medicaid Program Integrity; authorizing the agency to 
48         impose fines against a managed care plan that fails to 
49         submit an anti-fraud plan or make certain reports; 
50         authorizing the agency to adopt rules; directing the 
51         Auditor General and the Office of Program Policy 
52         Analysis and Government Accountability to review the 
53         Medicaid fraud and abuse processes in the Agency for 
54         Health Care Administration; requiring a report to the 
55         Legislature and Governor by a certain date; 
56         establishing the Medicaid claims adjudication project 
57         in the Agency for Health Care Administration to 
58         decrease the incidence of inaccurate payments and to 
59         improve the efficiency of the Medicaid claims 
60         processing system; amending s. 409.912, F.S.; 
61         authorizing the Agency for Health Care Administration 
62         to contract with an entity that provides comprehensive 
63         behavioral health care services to certain Medicaid 
64         recipients who are not enrolled in a Medicaid managed 
65         care plan or a Medicaid provider service network under 
66         certain circumstances; amending s. 409.91211, F.S.; 
67         revising certain provisions governing the Medicaid 
68         managed care pilot program to conform to the extension 
69         of the federal waiver; authorizing an administrative 
70         fee to be paid to the specialty plan for the 
71         coordination of services; transferring activities 
72         relating to public assistance fraud from the 
73         Department of Law Enforcement to the Division of 
74         Public Assistance Fraud in the Department of Financial 
75         Services by a type two transfer; providing effective 
76         dates. 
77 
78  Be It Enacted by the Legislature of the State of Florida: 
79 
80         Section 1. By July 1, 2010, the Agency for Health Care 
81  Administration shall begin the process of requesting an 
82  extension of the Section 1115 waiver and shall ensure that the 
83  waiver remains active and current. The agency shall report at 
84  least monthly to the Legislature on progress in negotiating for 
85  the extension of the waiver. Changes to the terms and conditions 
86  relating to the low-income pool must be approved by the 
87  Legislative Budget Commission. 
88         Section 2. (1) The Agency for Health Care Administration 
89  shall develop a methodology to ensure the availability of 
90  intergovernmental transfers in any expansion of prepaid managed 
91  care in the Medicaid program. The purpose of this methodology is 
92  to support providers that have historically served Medicaid 
93  recipients, including, but not limited to, safety net providers, 
94  trauma hospitals, children’s hospitals, statutory teaching 
95  hospitals, and medical and osteopathic physicians employed by or 
96  under contract with a medical school in this state. The agency 
97  may develop a supplemental capitation rate, risk pool, or 
98  incentive payment to plans that contract with these providers. 
99  The agency may develop the supplemental capitation rate to 
100  consider rates higher than the fee-for-service Medicaid rate 
101  when needed to ensure access and supported by funds provided by 
102  a locality. The agency shall evaluate the development of the 
103  rate cell to accurately reflect the underlying utilization to 
104  the maximum extent possible. The methodology may include interim 
105  rate adjustments as permitted under federal regulations. Any 
106  such methodology shall preserve federal funding to these 
107  entities and must be actuarially sound. 
108         (2) The Secretary of Health Care Administration shall 
109  appoint members and convene a technical advisory panel to advise 
110  the agency in the study and development of intergovernmental 
111  transfer distribution methods. The panel shall include 
112  representatives from contributing hospitals, medical schools, 
113  local governments, and managed care plans. The panel shall 
114  advise the agency regarding the best methods for ensuring the 
115  continued availability of intergovernmental transfers, specific 
116  issues to resolve in negotiations with the Centers for Medicare 
117  and Medicaid, and appropriate safeguards for appropriate 
118  implementation of any developed payment methodologies. 
119         (3) By January 1, 2011, the agency shall provide a report 
120  to the Speaker of the House of Representatives, the President of 
121  the Senate, and the Governor on the intergovernmental transfer 
122  methodologies developed. The agency shall not implement such 
123  methodologies without express legislative authority. 
124         Section 3. Section 624.35, Florida Statutes, is created to 
125  read: 
126         624.35 Short title.—Sections 624.35-624.352 may be cited as 
127  the “Medicaid and Public Assistance Fraud Strike Force Act.” 
128         Section 4. Section 624.351, Florida Statutes, is created to 
129  read: 
130         624.351 Medicaid and Public Assistance Fraud Strike Force.— 
131         (1) LEGISLATIVE FINDINGS.—The Legislature finds that there 
132  is a need to develop and implement a statewide strategy to 
133  coordinate state and local agencies, law enforcement entities, 
134  and investigative units in order to increase the effectiveness 
135  of programs and initiatives dealing with the prevention, 
136  detection, and prosecution of Medicaid and public assistance 
137  fraud. 
138         (2) ESTABLISHMENT.—The Medicaid and Public Assistance Fraud 
139  Strike Force is created within the department to oversee and 
140  coordinate state and local efforts to eliminate Medicaid and 
141  public assistance fraud and to recover state and federal funds. 
142  The strike force shall serve in an advisory capacity and provide 
143  recommendations and policy alternatives to the Chief Financial 
144  Officer. 
145         (3) MEMBERSHIP.—The strike force shall consist of the 
146  following 11 members who may not designate anyone to serve in 
147  their place: 
148         (a) The Chief Financial Officer, who shall serve as chair. 
149         (b) The Attorney General, who shall serve as vice chair. 
150         (c) The executive director of the Department of Law 
151  Enforcement. 
152         (d) The Secretary of Health Care Administration. 
153         (e) The Secretary of Children and Family Services. 
154         (f) The State Surgeon General. 
155         (g) Five members appointed by the Chief Financial Officer, 
156  consisting of two sheriffs, two chiefs of police, and one state 
157  attorney. When making these appointments, the Chief Financial 
158  Officer shall consider representation by geography, population, 
159  ethnicity, and other relevant factors in order to ensure that 
160  the membership of the strike force is representative of the 
161  state as a whole. 
162         (4) TERMS OF MEMBERSHIP; COMPENSATION; STAFF.— 
163         (a) The five members appointed by the Chief Financial 
164  Officer shall be appointed to 4-year terms; however, for the 
165  purpose of providing staggered terms, of the initial 
166  appointments, two members shall be appointed to a 2-year term, 
167  two members shall be appointed to a 3-year term, and one member 
168  shall be appointed to a 4-year term. Each of the remaining 
169  members is a standing member of the strike force and may not 
170  serve beyond the time he or she holds the position that was the 
171  basis for strike force membership. A vacancy shall be filled in 
172  the same manner as the original appointment but only for the 
173  unexpired term. 
174         (b) The Legislature finds that the strike force serves a 
175  legitimate state, county, and municipal purpose and that service 
176  on the strike force is consistent with a member’s principal 
177  service in a public office or employment. Therefore membership 
178  on the strike force does not disqualify a member from holding 
179  any other public office or from being employed by a public 
180  entity, except that a member of the Legislature may not serve on 
181  the strike force. 
182         (c) Members of the strike force shall serve without 
183  compensation, but are entitled to reimbursement for per diem and 
184  travel expenses pursuant to s. 112.061. Reimbursements may be 
185  paid from appropriations provided to the department by the 
186  Legislature for the purposes of this section. 
187         (d) The Chief Financial Officer shall appoint a chief of 
188  staff for the strike force who must have experience, education, 
189  and expertise in the fields of law, prosecution, or fraud 
190  investigations and shall serve at the pleasure of the Chief 
191  Financial Officer. The department shall provide the strike force 
192  with staff necessary to assist the strike force in the 
193  performance of its duties. 
194         (5) MEETINGS.—The strike force shall hold its 
195  organizational session by March 1, 2011. Thereafter, the strike 
196  force shall meet at least four times per year. Additional 
197  meetings may be held if the chair determines that extraordinary 
198  circumstances require an additional meeting. Members may appear 
199  by electronic means. A majority of the members of the strike 
200  force constitutes a quorum. 
201         (6) STRIKE FORCE DUTIES.—The strike force shall provide 
202  advice and make recommendations, as necessary, to the Chief 
203  Financial Officer. 
204         (a) The strike force may advise the Chief Financial Officer 
205  on initiatives that include, but are not limited to: 
206         1. Conducting a census of local, state, and federal efforts 
207  to address Medicaid and public assistance fraud in this state, 
208  including fraud detection, prevention, and prosecution, in order 
209  to discern overlapping missions, maximize existing resources, 
210  and strengthen current programs. 
211         2. Developing a strategic plan for coordinating and 
212  targeting state and local resources for preventing and 
213  prosecuting Medicaid and public assistance fraud. The plan must 
214  identify methods to enhance multiagency efforts that contribute 
215  to achieving the state’s goal of eliminating Medicaid and public 
216  assistance fraud. 
217         3. Identifying methods to implement innovative technology 
218  and data sharing in order to detect and analyze Medicaid and 
219  public assistance fraud with speed and efficiency. 
220         4. Establishing a program to provide grants to state and 
221  local agencies that develop and implement effective Medicaid and 
222  public assistance fraud prevention, detection, and investigation 
223  programs, which are evaluated by the strike force and ranked by 
224  their potential to contribute to achieving the state’s goal of 
225  eliminating Medicaid and public assistance fraud. The grant 
226  program may also provide startup funding for new initiatives by 
227  local and state law enforcement or administrative agencies to 
228  combat Medicaid and public assistance fraud. 
229         5. Developing and promoting crime prevention services and 
230  educational programs that serve the public, including, but not 
231  limited to, a well-publicized rewards program for the 
232  apprehension and conviction of criminals who perpetrate Medicaid 
233  and public assistance fraud. 
234         6. Providing grants, contingent upon appropriation, for 
235  multiagency or state and local Medicaid and public assistance 
236  fraud efforts, which include, but are not limited to: 
237         a. Providing for a Medicaid and public assistance fraud 
238  prosecutor in the Office of the Statewide Prosecutor. 
239         b. Providing assistance to state attorneys for support 
240  services or equipment, or for the hiring of assistant state 
241  attorneys, as needed, to prosecute Medicaid and public 
242  assistance fraud cases. 
243         c. Providing assistance to judges for support services or 
244  for the hiring of senior judges, as needed, so that Medicaid and 
245  public assistance fraud cases can be heard expeditiously. 
246         (b) The strike force shall receive periodic reports from 
247  state agencies, law enforcement officers, investigators, 
248  prosecutors, and coordinating teams regarding Medicaid and 
249  public assistance criminal and civil investigations. Such 
250  reports may include discussions regarding significant factors 
251  and trends relevant to a statewide Medicaid and public 
252  assistance fraud strategy. 
253         (7) REPORTS.—The strike force shall annually prepare and 
254  submit a report on its activities and recommendations, by 
255  October 1, to the President of the Senate, the Speaker of the 
256  House of Representatives, the Governor, and the chairs of the 
257  House of Representatives and Senate committees that have 
258  substantive jurisdiction over Medicaid and public assistance 
259  fraud. 
260         Section 5. Section 624.352, Florida Statutes, is created to 
261  read: 
262         624.352 Interagency agreements to detect and deter Medicaid 
263  and public assistance fraud.— 
264         (1) The Chief Financial Officer shall prepare model 
265  interagency agreements for the coordination of prevention, 
266  investigation, and prosecution of Medicaid and public assistance 
267  fraud to be known as “Strike Force” agreements. Parties to such 
268  agreements may include any agency that is headed by a Cabinet 
269  officer, the Governor, the Governor and Cabinet, a collegial 
270  body, or any federal, state, or local law enforcement agency. 
271         (2) The agreements must include, but are not limited to: 
272         (a) Establishing the agreement’s purpose, mission, 
273  authority, organizational structure, procedures, supervision, 
274  operations, deputations, funding, expenditures, property and 
275  equipment, reports and records, assets and forfeitures, media 
276  policy, liability, and duration. 
277         (b) Requiring that parties to an agreement have appropriate 
278  powers and authority relative to the purpose and mission of the 
279  agreement. 
280         Section 6. Section 16.59, Florida Statutes, is amended to 
281  read: 
282         16.59 Medicaid fraud control.—The Medicaid Fraud Control 
283  Unit There is created in the Department of Legal Affairs to the 
284  Medicaid Fraud Control Unit, which may investigate all 
285  violations of s. 409.920 and any criminal violations discovered 
286  during the course of those investigations. The Medicaid Fraud 
287  Control Unit may refer any criminal violation so uncovered to 
288  the appropriate prosecuting authority. The offices of the 
289  Medicaid Fraud Control Unit, and the offices of the Agency for 
290  Health Care Administration Medicaid program integrity program, 
291  and the Divisions of Insurance Fraud and Public Assistance Fraud 
292  within the Department of Financial Services shall, to the extent 
293  possible, be collocated; however, positions dedicated to 
294  Medicaid managed care fraud within the Medicaid Fraud Control 
295  Unit shall be collocated with the Division of Insurance Fraud. 
296  The Agency for Health Care Administration, and the Department of 
297  Legal Affairs, and the Divisions of Insurance Fraud and Public 
298  Assistance Fraud within the Department of Financial Services 
299  shall conduct joint training and other joint activities designed 
300  to increase communication and coordination in recovering 
301  overpayments. 
302         Section 7. Paragraph (o) is added to subsection (2) of 
303  section 20.121, Florida Statutes, to read: 
304         20.121 Department of Financial Services.—There is created a 
305  Department of Financial Services. 
306         (2) DIVISIONS.—The Department of Financial Services shall 
307  consist of the following divisions: 
308         (o) The Division of Public Assistance Fraud. 
309         Section 8. Paragraph (b) of subsection (7) of section 
310  411.01, Florida Statutes, is amended to read: 
311         411.01 School readiness programs; early learning 
312  coalitions.— 
313         (7) PARENTAL CHOICE.— 
314         (b) If it is determined that a provider has provided any 
315  cash to the beneficiary in return for receiving the purchase 
316  order, the early learning coalition or its fiscal agent shall 
317  refer the matter to the Department of Financial Services 
318  pursuant to s. 414.411 Division of Public Assistance Fraud for 
319  investigation. 
320         Section 9. Subsection (2) of section 414.33, Florida 
321  Statutes, is amended to read: 
322         414.33 Violations of food stamp program.— 
323         (2) In addition, the department shall establish procedures 
324  for referring to the Department of Law Enforcement any case that 
325  involves a suspected violation of federal or state law or rules 
326  governing the administration of the food stamp program to the 
327  Department of Financial Services pursuant to s. 414.411. 
328         Section 10. Subsection (9) of section 414.39, Florida 
329  Statutes, is amended to read: 
330         414.39 Fraud.— 
331         (9) All records relating to investigations of public 
332  assistance fraud in the custody of the department and the Agency 
333  for Health Care Administration are available for examination by 
334  the Department of Financial Services Law Enforcement pursuant to 
335  s. 414.411 943.401 and are admissible into evidence in 
336  proceedings brought under this section as business records 
337  within the meaning of s. 90.803(6). 
338         Section 11. Section 943.401, Florida Statutes, is 
339  transferred, renumbered as section 414.411, Florida Statutes, 
340  and amended to read: 
341         414.411 943.401 Public assistance fraud.— 
342         (1)(a) The Department of Financial Services Law Enforcement 
343  shall investigate all public assistance provided to residents of 
344  the state or provided to others by the state. In the course of 
345  such investigation the department of Law Enforcement shall 
346  examine all records, including electronic benefits transfer 
347  records and make inquiry of all persons who may have knowledge 
348  as to any irregularity incidental to the disbursement of public 
349  moneys, food stamps, or other items or benefits authorizations 
350  to recipients. 
351         (b) All public assistance recipients, as a condition 
352  precedent to qualification for public assistance received and as 
353  defined under the provisions of chapter 409, chapter 411, or 
354  this chapter 414, must shall first give in writing, to the 
355  Agency for Health Care Administration, the Department of Health, 
356  the Agency for Workforce Innovation, and the Department of 
357  Children and Family Services, as appropriate, and to the 
358  Department of Financial Services Law Enforcement, consent to 
359  make inquiry of past or present employers and records, financial 
360  or otherwise. 
361         (2) In the conduct of such investigation the Department of 
362  Financial Services Law Enforcement may employ persons having 
363  such qualifications as are useful in the performance of this 
364  duty. 
365         (3) The results of such investigation shall be reported by 
366  the Department of Financial Services Law Enforcement to the 
367  appropriate legislative committees, the Agency for Health Care 
368  Administration, the Department of Health, the Agency for 
369  Workforce Innovation, and the Department of Children and Family 
370  Services, and to such others as the department of Law 
371  Enforcement may determine. 
372         (4) The Department of Health and the Department of Children 
373  and Family Services shall report to the Department of Financial 
374  Services Law Enforcement the final disposition of all cases 
375  wherein action has been taken pursuant to s. 414.39, based upon 
376  information furnished by the Department of Financial Services 
377  Law Enforcement. 
378         (5) All lawful fees and expenses of officers and witnesses, 
379  expenses incident to taking testimony and transcripts of 
380  testimony and proceedings are a proper charge to the Department 
381  of Financial Services Law Enforcement. 
382         (6) The provisions of this section shall be liberally 
383  construed in order to carry out effectively the purposes of this 
384  section in the interest of protecting public moneys and other 
385  public property. 
386         Section 12. Section 409.91212, Florida Statutes, is created 
387  to read: 
388         409.91212 Medicaid managed care fraud.— 
389         (1) Each managed care plan, as defined in s. 409.920(1)(e), 
390  shall adopt an anti-fraud plan addressing the detection and 
391  prevention of overpayments, abuse, and fraud relating to the 
392  provision of and payment for Medicaid services and submit the 
393  plan to the Office of Medicaid Program Integrity within the 
394  agency for approval. At a minimum, the anti-fraud plan must 
395  include: 
396         (a) A written description or chart outlining the 
397  organizational arrangement of the plan’s personnel who are 
398  responsible for the investigation and reporting of possible 
399  overpayment, abuse, or fraud; 
400         (b) A description of the plan’s procedures for detecting 
401  and investigating possible acts of fraud, abuse, and 
402  overpayment; 
403         (c) A description of the plan’s procedures for the 
404  mandatory reporting of possible overpayment, abuse, or fraud to 
405  the Office of Medicaid Program Integrity within the agency; 
406         (d) A description of the plan’s program and procedures for 
407  educating and training personnel on how to detect and prevent 
408  fraud, abuse, and overpayment; 
409         (e) The name, address, telephone number, e-mail address, 
410  and fax number of the individual responsible for carrying out 
411  the anti-fraud plan; and 
412         (f) A summary of the results of the investigations of 
413  fraud, abuse, or overpayment which were conducted during the 
414  previous year by the managed care organization’s fraud 
415  investigative unit. 
416         (2) A managed care plan that provides Medicaid services 
417  shall: 
418         (a) Establish and maintain a fraud investigative unit to 
419  investigate possible acts of fraud, abuse, and overpayment; or 
420         (b) Contract for the investigation of possible fraudulent 
421  or abusive acts by Medicaid recipients, persons providing 
422  services to Medicaid recipients, or any other persons. 
423         (3) If a managed care plan contracts for the investigation 
424  of fraudulent claims and other types of program abuse by 
425  recipients or service providers, the managed care plan shall 
426  file the following with the Office of Medicaid Program Integrity 
427  within the agency for approval before the plan executes any 
428  contracts for fraud and abuse prevention and detection: 
429         (a) A copy of the written contract between the plan and the 
430  contracting entity; 
431         (b) The names, addresses, telephone numbers, e-mail 
432  addresses, and fax numbers of the principals of the entity with 
433  which the managed care plan has contracted; and 
434         (c) A description of the qualifications of the principals 
435  of the entity with which the managed care plan has contracted. 
436         (4) On or before September 1 of each year, each managed 
437  care plan shall report to the Office of Medicaid Program 
438  Integrity within the agency on its experience in implementing an 
439  anti-fraud plan, as provided under subsection (1), and, if 
440  applicable, conducting or contracting for investigations of 
441  possible fraudulent or abusive acts as provided under this 
442  section for the prior state fiscal year. The report must 
443  include, at a minimum: 
444         (a) The dollar amount of losses and recoveries attributable 
445  to overpayment, abuse, and fraud. 
446         (b) The number of referrals to the Office of Medicaid 
447  Program Integrity during the prior year. 
448         (5) If a managed care plan fails to timely submit a final 
449  acceptable anti-fraud plan, fails to timely submit its annual 
450  report, fails to implement its anti-fraud plan or investigative 
451  unit, if applicable, or otherwise refuses to comply with this 
452  section, the agency shall impose: 
453         (a) An administrative fine of $2,000 per calendar day for 
454  failure to submit an acceptable anti-fraud plan or report until 
455  the agency deems the managed care plan or report to be in 
456  compliance; 
457         (b) An administrative fine of not more than $10,000 for 
458  failure by a managed care plan to implement an anti-fraud plan 
459  or investigative unit, as applicable; or 
460         (c) The administrative fines pursuant to paragraphs (a) and 
461  (b). 
462         (6) Each managed care plan shall report all suspected or 
463  confirmed instances of provider or recipient fraud or abuse 
464  within 15 calendar days after detection to the Office of 
465  Medicaid Program Integrity within the agency. At a minimum the 
466  report must contain the name of the provider or recipient, the 
467  Medicaid billing number or tax identification number, and a 
468  description of the fraudulent or abusive act. The Office of 
469  Medicaid Program Integrity in the agency shall forward the 
470  report of suspected overpayment, abuse, or fraud to the 
471  appropriate investigative unit, including, but not limited to, 
472  the Bureau of Medicaid program integrity, the Medicaid fraud 
473  control unit, the Division of Public Assistance Fraud, the 
474  Division of Insurance Fraud, or the Department of Law 
475  Enforcement. 
476         (a) Failure to timely report shall result in an 
477  administrative fine of $1,000 per calendar day after the 15th 
478  day of detection. 
479         (b) Failure to timely report may result in additional 
480  administrative, civil, or criminal penalties. 
481         (7) The agency may adopt rules to administer this section. 
482         Section 13. Review of the Medicaid fraud and abuse 
483  processes.— 
484         (1) The Auditor General and the Office of Program Policy 
485  Analysis and Government Accountability shall review and evaluate 
486  the Agency for Health Care Administration’s Medicaid fraud and 
487  abuse systems, including the Medicaid program integrity program. 
488  The reviewers may access Medicaid-related information and data 
489  from the Attorney General’s Medicaid Fraud Control Unit, the 
490  Department of Health, the Department of Elderly Affairs, the 
491  Agency for Persons with Disabilities, and the Department of 
492  Children and Family Services, as necessary, to conduct the 
493  review. The review must include, but is not limited to: 
494         (a) An evaluation of current Medicaid policies and the 
495  Medicaid fiscal agent; 
496         (b) An analysis of the Medicaid fraud and abuse prevention 
497  and detection processes, including agency contracts, Medicaid 
498  databases, and internal control risk assessments; 
499         (c) A comprehensive evaluation of the effectiveness of the 
500  current laws, rules, and contractual requirements that govern 
501  Medicaid managed care entities; 
502         (d) An evaluation of the agency’s Medicaid managed care 
503  oversight processes; 
504         (e) Recommendations to improve the Medicaid claims 
505  adjudication process, to increase the overall efficiency of the 
506  Medicaid program, and to reduce Medicaid overpayments; and 
507         (f) Operational and legislative recommendations to improve 
508  the prevention and detection of fraud and abuse in the Medicaid 
509  managed care program. 
510         (2) The Auditor General’s Office and the Office of Program 
511  Policy Analysis and Government Accountability may contract with 
512  technical consultants to assist in the performance of the 
513  review. The Auditor General and the Office of Program Policy 
514  Analysis and Government Accountability shall report to the 
515  President of the Senate, the Speaker of the House of 
516  Representatives, and the Governor by December 1, 2011. 
517         Section 14. Medicaid claims adjudication project.—The 
518  Agency for Health Care Administration shall issue a competitive 
519  procurement pursuant to chapter 287, Florida Statutes, with a 
520  third-party vendor, at no cost to the state, to provide a real 
521  time, front-end database to augment the Medicaid fiscal agent 
522  program edits and claims adjudication process. The vendor shall 
523  provide an interface with the Medicaid fiscal agent to decrease 
524  inaccurate payment to Medicaid providers and improve the overall 
525  efficiency of the Medicaid claims-processing system. 
526         Section 15. Effective July 1, 2010, paragraph (b) of 
527  subsection (4) of section 409.912, Florida Statutes, is amended, 
528  and paragraph (d) of that subsection is republished, to read: 
529         409.912 Cost-effective purchasing of health care.—The 
530  agency shall purchase goods and services for Medicaid recipients 
531  in the most cost-effective manner consistent with the delivery 
532  of quality medical care. To ensure that medical services are 
533  effectively utilized, the agency may, in any case, require a 
534  confirmation or second physician’s opinion of the correct 
535  diagnosis for purposes of authorizing future services under the 
536  Medicaid program. This section does not restrict access to 
537  emergency services or poststabilization care services as defined 
538  in 42 C.F.R. part 438.114. Such confirmation or second opinion 
539  shall be rendered in a manner approved by the agency. The agency 
540  shall maximize the use of prepaid per capita and prepaid 
541  aggregate fixed-sum basis services when appropriate and other 
542  alternative service delivery and reimbursement methodologies, 
543  including competitive bidding pursuant to s. 287.057, designed 
544  to facilitate the cost-effective purchase of a case-managed 
545  continuum of care. The agency shall also require providers to 
546  minimize the exposure of recipients to the need for acute 
547  inpatient, custodial, and other institutional care and the 
548  inappropriate or unnecessary use of high-cost services. The 
549  agency shall contract with a vendor to monitor and evaluate the 
550  clinical practice patterns of providers in order to identify 
551  trends that are outside the normal practice patterns of a 
552  provider’s professional peers or the national guidelines of a 
553  provider’s professional association. The vendor must be able to 
554  provide information and counseling to a provider whose practice 
555  patterns are outside the norms, in consultation with the agency, 
556  to improve patient care and reduce inappropriate utilization. 
557  The agency may mandate prior authorization, drug therapy 
558  management, or disease management participation for certain 
559  populations of Medicaid beneficiaries, certain drug classes, or 
560  particular drugs to prevent fraud, abuse, overuse, and possible 
561  dangerous drug interactions. The Pharmaceutical and Therapeutics 
562  Committee shall make recommendations to the agency on drugs for 
563  which prior authorization is required. The agency shall inform 
564  the Pharmaceutical and Therapeutics Committee of its decisions 
565  regarding drugs subject to prior authorization. The agency is 
566  authorized to limit the entities it contracts with or enrolls as 
567  Medicaid providers by developing a provider network through 
568  provider credentialing. The agency may competitively bid single 
569  source-provider contracts if procurement of goods or services 
570  results in demonstrated cost savings to the state without 
571  limiting access to care. The agency may limit its network based 
572  on the assessment of beneficiary access to care, provider 
573  availability, provider quality standards, time and distance 
574  standards for access to care, the cultural competence of the 
575  provider network, demographic characteristics of Medicaid 
576  beneficiaries, practice and provider-to-beneficiary standards, 
577  appointment wait times, beneficiary use of services, provider 
578  turnover, provider profiling, provider licensure history, 
579  previous program integrity investigations and findings, peer 
580  review, provider Medicaid policy and billing compliance records, 
581  clinical and medical record audits, and other factors. Providers 
582  shall not be entitled to enrollment in the Medicaid provider 
583  network. The agency shall determine instances in which allowing 
584  Medicaid beneficiaries to purchase durable medical equipment and 
585  other goods is less expensive to the Medicaid program than long 
586  term rental of the equipment or goods. The agency may establish 
587  rules to facilitate purchases in lieu of long-term rentals in 
588  order to protect against fraud and abuse in the Medicaid program 
589  as defined in s. 409.913. The agency may seek federal waivers 
590  necessary to administer these policies. 
591         (4) The agency may contract with: 
592         (b) An entity that is providing comprehensive behavioral 
593  health care services to certain Medicaid recipients through a 
594  capitated, prepaid arrangement pursuant to the federal waiver 
595  provided for by s. 409.905(5). Such entity must be licensed 
596  under chapter 624, chapter 636, or chapter 641, or authorized 
597  under paragraph (c) or paragraph (d), and must possess the 
598  clinical systems and operational competence to manage risk and 
599  provide comprehensive behavioral health care to Medicaid 
600  recipients. As used in this paragraph, the term “comprehensive 
601  behavioral health care services” means covered mental health and 
602  substance abuse treatment services that are available to 
603  Medicaid recipients. The secretary of the Department of Children 
604  and Family Services shall approve provisions of procurements 
605  related to children in the department’s care or custody before 
606  enrolling such children in a prepaid behavioral health plan. Any 
607  contract awarded under this paragraph must be competitively 
608  procured. In developing the behavioral health care prepaid plan 
609  procurement document, the agency shall ensure that the 
610  procurement document requires the contractor to develop and 
611  implement a plan to ensure compliance with s. 394.4574 related 
612  to services provided to residents of licensed assisted living 
613  facilities that hold a limited mental health license. Except as 
614  provided in subparagraph 8., and except in counties where the 
615  Medicaid managed care pilot program is authorized pursuant to s. 
616  409.91211, the agency shall seek federal approval to contract 
617  with a single entity meeting these requirements to provide 
618  comprehensive behavioral health care services to all Medicaid 
619  recipients not enrolled in a Medicaid managed care plan 
620  authorized under s. 409.91211, a provider service network 
621  authorized under paragraph (d), or a Medicaid health maintenance 
622  organization in an AHCA area. In an AHCA area where the Medicaid 
623  managed care pilot program is authorized pursuant to s. 
624  409.91211 in one or more counties, the agency may procure a 
625  contract with a single entity to serve the remaining counties as 
626  an AHCA area or the remaining counties may be included with an 
627  adjacent AHCA area and are subject to this paragraph. Each 
628  entity must offer a sufficient choice of providers in its 
629  network to ensure recipient access to care and the opportunity 
630  to select a provider with whom they are satisfied. The network 
631  shall include all public mental health hospitals. To ensure 
632  unimpaired access to behavioral health care services by Medicaid 
633  recipients, all contracts issued pursuant to this paragraph must 
634  require 80 percent of the capitation paid to the managed care 
635  plan, including health maintenance organizations and capitated 
636  provider service networks, to be expended for the provision of 
637  behavioral health care services. If the managed care plan 
638  expends less than 80 percent of the capitation paid for the 
639  provision of behavioral health care services, the difference 
640  shall be returned to the agency. The agency shall provide the 
641  plan with a certification letter indicating the amount of 
642  capitation paid during each calendar year for behavioral health 
643  care services pursuant to this section. The agency may reimburse 
644  for substance abuse treatment services on a fee-for-service 
645  basis until the agency finds that adequate funds are available 
646  for capitated, prepaid arrangements. 
647         1. By January 1, 2001, the agency shall modify the 
648  contracts with the entities providing comprehensive inpatient 
649  and outpatient mental health care services to Medicaid 
650  recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk 
651  Counties, to include substance abuse treatment services. 
652         2. By July 1, 2003, the agency and the Department of 
653  Children and Family Services shall execute a written agreement 
654  that requires collaboration and joint development of all policy, 
655  budgets, procurement documents, contracts, and monitoring plans 
656  that have an impact on the state and Medicaid community mental 
657  health and targeted case management programs. 
658         3. Except as provided in subparagraph 8., by July 1, 2006, 
659  the agency and the Department of Children and Family Services 
660  shall contract with managed care entities in each AHCA area 
661  except area 6 or arrange to provide comprehensive inpatient and 
662  outpatient mental health and substance abuse services through 
663  capitated prepaid arrangements to all Medicaid recipients who 
664  are eligible to participate in such plans under federal law and 
665  regulation. In AHCA areas where eligible individuals number less 
666  than 150,000, the agency shall contract with a single managed 
667  care plan to provide comprehensive behavioral health services to 
668  all recipients who are not enrolled in a Medicaid health 
669  maintenance organization, a provider service network authorized 
670  under paragraph (d), or a Medicaid capitated managed care plan 
671  authorized under s. 409.91211. The agency may contract with more 
672  than one comprehensive behavioral health provider to provide 
673  care to recipients who are not enrolled in a Medicaid capitated 
674  managed care plan authorized under s. 409.91211, a provider 
675  service network authorized under paragraph (d), or a Medicaid 
676  health maintenance organization in AHCA areas where the eligible 
677  population exceeds 150,000. In an AHCA area where the Medicaid 
678  managed care pilot program is authorized pursuant to s. 
679  409.91211 in one or more counties, the agency may procure a 
680  contract with a single entity to serve the remaining counties as 
681  an AHCA area or the remaining counties may be included with an 
682  adjacent AHCA area and shall be subject to this paragraph. 
683  Contracts for comprehensive behavioral health providers awarded 
684  pursuant to this section shall be competitively procured. Both 
685  for-profit and not-for-profit corporations are eligible to 
686  compete. Managed care plans contracting with the agency under 
687  subsection (3) or paragraph (d), shall provide and receive 
688  payment for the same comprehensive behavioral health benefits as 
689  provided in AHCA rules, including handbooks incorporated by 
690  reference. In AHCA area 11, the agency shall contract with at 
691  least two comprehensive behavioral health care providers to 
692  provide behavioral health care to recipients in that area who 
693  are enrolled in, or assigned to, the MediPass program. One of 
694  the behavioral health care contracts must be with the existing 
695  provider service network pilot project, as described in 
696  paragraph (d), for the purpose of demonstrating the cost 
697  effectiveness of the provision of quality mental health services 
698  through a public hospital-operated managed care model. Payment 
699  shall be at an agreed-upon capitated rate to ensure cost 
700  savings. Of the recipients in area 11 who are assigned to 
701  MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those 
702  MediPass-enrolled recipients shall be assigned to the existing 
703  provider service network in area 11 for their behavioral care. 
704         4. By October 1, 2003, the agency and the department shall 
705  submit a plan to the Governor, the President of the Senate, and 
706  the Speaker of the House of Representatives which provides for 
707  the full implementation of capitated prepaid behavioral health 
708  care in all areas of the state. 
709         a. Implementation shall begin in 2003 in those AHCA areas 
710  of the state where the agency is able to establish sufficient 
711  capitation rates. 
712         b. If the agency determines that the proposed capitation 
713  rate in any area is insufficient to provide appropriate 
714  services, the agency may adjust the capitation rate to ensure 
715  that care will be available. The agency and the department may 
716  use existing general revenue to address any additional required 
717  match but may not over-obligate existing funds on an annualized 
718  basis. 
719         c. Subject to any limitations provided in the General 
720  Appropriations Act, the agency, in compliance with appropriate 
721  federal authorization, shall develop policies and procedures 
722  that allow for certification of local and state funds. 
723         5. Children residing in a statewide inpatient psychiatric 
724  program, or in a Department of Juvenile Justice or a Department 
725  of Children and Family Services residential program approved as 
726  a Medicaid behavioral health overlay services provider may not 
727  be included in a behavioral health care prepaid health plan or 
728  any other Medicaid managed care plan pursuant to this paragraph. 
729         6. In converting to a prepaid system of delivery, the 
730  agency shall in its procurement document require an entity 
731  providing only comprehensive behavioral health care services to 
732  prevent the displacement of indigent care patients by enrollees 
733  in the Medicaid prepaid health plan providing behavioral health 
734  care services from facilities receiving state funding to provide 
735  indigent behavioral health care, to facilities licensed under 
736  chapter 395 which do not receive state funding for indigent 
737  behavioral health care, or reimburse the unsubsidized facility 
738  for the cost of behavioral health care provided to the displaced 
739  indigent care patient. 
740         7. Traditional community mental health providers under 
741  contract with the Department of Children and Family Services 
742  pursuant to part IV of chapter 394, child welfare providers 
743  under contract with the Department of Children and Family 
744  Services in areas 1 and 6, and inpatient mental health providers 
745  licensed pursuant to chapter 395 must be offered an opportunity 
746  to accept or decline a contract to participate in any provider 
747  network for prepaid behavioral health services. 
748         8. All Medicaid-eligible children, except children in area 
749  1 and children in Highlands County, Hardee County, Polk County, 
750  or Manatee County of area 6, that are open for child welfare 
751  services in the HomeSafeNet system, shall receive their 
752  behavioral health care services through a specialty prepaid plan 
753  operated by community-based lead agencies through a single 
754  agency or formal agreements among several agencies. The 
755  specialty prepaid plan must result in savings to the state 
756  comparable to savings achieved in other Medicaid managed care 
757  and prepaid programs. Such plan must provide mechanisms to 
758  maximize state and local revenues. The specialty prepaid plan 
759  shall be developed by the agency and the Department of Children 
760  and Family Services. The agency may seek federal waivers to 
761  implement this initiative. Medicaid-eligible children whose 
762  cases are open for child welfare services in the HomeSafeNet 
763  system and who reside in AHCA area 10 are exempt from the 
764  specialty prepaid plan upon the development of a service 
765  delivery mechanism for children who reside in area 10 as 
766  specified in s. 409.91211(3)(dd). 
767         (d) A provider service network may be reimbursed on a fee 
768  for-service or prepaid basis. A provider service network which 
769  is reimbursed by the agency on a prepaid basis shall be exempt 
770  from parts I and III of chapter 641, but must comply with the 
771  solvency requirements in s. 641.2261(2) and meet appropriate 
772  financial reserve, quality assurance, and patient rights 
773  requirements as established by the agency. Medicaid recipients 
774  assigned to a provider service network shall be chosen equally 
775  from those who would otherwise have been assigned to prepaid 
776  plans and MediPass. The agency is authorized to seek federal 
777  Medicaid waivers as necessary to implement the provisions of 
778  this section. Any contract previously awarded to a provider 
779  service network operated by a hospital pursuant to this 
780  subsection shall remain in effect for a period of 3 years 
781  following the current contract expiration date, regardless of 
782  any contractual provisions to the contrary. A provider service 
783  network is a network established or organized and operated by a 
784  health care provider, or group of affiliated health care 
785  providers, including minority physician networks and emergency 
786  room diversion programs that meet the requirements of s. 
787  409.91211, which provides a substantial proportion of the health 
788  care items and services under a contract directly through the 
789  provider or affiliated group of providers and may make 
790  arrangements with physicians or other health care professionals, 
791  health care institutions, or any combination of such individuals 
792  or institutions to assume all or part of the financial risk on a 
793  prospective basis for the provision of basic health services by 
794  the physicians, by other health professionals, or through the 
795  institutions. The health care providers must have a controlling 
796  interest in the governing body of the provider service network 
797  organization. 
798         Section 16. Effective July 1, 2010, paragraphs (e) and (dd) 
799  of subsection (3) of section 409.91211, Florida Statutes, are 
800  amended to read: 
801         409.91211 Medicaid managed care pilot program.— 
802         (3) The agency shall have the following powers, duties, and 
803  responsibilities with respect to the pilot program: 
804         (e) To implement policies and guidelines for phasing in 
805  financial risk for approved provider service networks that, for 
806  purposes of this paragraph, include the Children’s Medical 
807  Services Network, over the a 5-year period of the waiver and the 
808  extension thereof. These policies and guidelines must include an 
809  option for a provider service network to be paid fee-for-service 
810  rates. For any provider service network established in a managed 
811  care pilot area, the option to be paid fee-for-service rates 
812  must include a savings-settlement mechanism that is consistent 
813  with s. 409.912(44). This model must be converted to a risk 
814  adjusted capitated rate by the beginning of the final sixth year 
815  of operation under the waiver extension, and may be converted 
816  earlier at the option of the provider service network. Federally 
817  qualified health centers may be offered an opportunity to accept 
818  or decline a contract to participate in any provider network for 
819  prepaid primary care services. 
820         (dd) To implement service delivery mechanisms within a 
821  specialty plan in area 10 capitated managed care plans to 
822  provide behavioral health care services Medicaid services as 
823  specified in ss. 409.905 and 409.906 to Medicaid-eligible 
824  children whose cases are open for child welfare services in the 
825  HomeSafeNet system. These services must be coordinated with 
826  community-based care providers as specified in s. 409.1671, 
827  where available, and be sufficient to meet the medical, 
828  developmental, behavioral, and emotional needs of these 
829  children. Children in area 10 who have an open case in the 
830  HomeSafeNet system shall be enrolled into the specialty plan. 
831  These service delivery mechanisms must be implemented no later 
832  than July 1, 2011 2008, in AHCA area 10 in order for the 
833  children in AHCA area 10 to remain exempt from the statewide 
834  plan under s. 409.912(4)(b)8. An administrative fee may be paid 
835  to the specialty plan for the coordination of services based on 
836  the receipt of the state share of that fee being provided 
837  through intergovernmental transfers. 
838         Section 17. All powers, duties, functions, records, 
839  offices, personnel, property, pending issues and existing 
840  contracts, administrative authority, administrative rules, and 
841  unexpended balances of appropriations, allocations, and other 
842  funds relating to public assistance fraud in the Department of 
843  Law Enforcement are transferred by a type two transfer, as 
844  defined in s. 20.06(2), Florida Statutes, to the Division of 
845  Public Assistance Fraud in the Department of Financial Services. 
846         Section 18. Except as otherwise expressly provided in this 
847  act and except for sections 1, 2, 12, 13, and 14 of this act and 
848  this section, which shall take effect upon this act becoming a 
849  law, this act shall take effect January 1, 2011.