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

NOTE: There are more recent revisions of this legislation. Read Latest Draft

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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-Engrossed.html

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CS for CS for SB 1484                            First Engrossed 
20101484e1 
1                        A bill to be entitled 
2         An act relating to Medicaid; amending s. 409.912, 
3         F.S.; authorizing the Agency for Health Care 
4         Administration to contract with an entity for the 
5         provision of comprehensive behavioral health care 
6         services to certain Medicaid recipients who are not 
7         enrolled in a Medicaid managed care plan or a Medicaid 
8         provider service network under certain circumstances; 
9         requiring the agency to impose a fine against a person 
10         under contract with the agency who violates certain 
11         provisions; requiring an entity that contracts with 
12         the agency as a managed care plan to post a surety 
13         bond with the agency or maintain an account of a 
14         specified sum; requiring the agency to pursue the 
15         entity if the entity terminates the contract with the 
16         agency before the end date of the contract; amending 
17         s. 409.91211, F.S.; extending by 3 years the statewide 
18         implementation of an enhanced service delivery system 
19         for the Florida Medicaid program; providing for the 
20         expansion of the pilot project into counties that have 
21         two or more plans and the capacity to serve the 
22         designated population; requiring that the agency 
23         provide certain specified data to the recipient when 
24         selecting a capitated managed care plan; revising 
25         certain requirements for entities performing choice 
26         counseling for recipients; requiring the agency to 
27         provide behavioral health care services to Medicaid 
28         eligible children; extending a date by which the 
29         behavioral health care services will be delivered to 
30         children; deleting a provision under which certain 
31         Medicaid recipients who are not currently enrolled in 
32         a capitated managed care plan upon implementation are 
33         not eligible for specified services for the amount of 
34         time that the recipients do not enroll in a capitated 
35         managed care network; authorizing the agency to extend 
36         the time to continue operation of the pilot program; 
37         requiring that the agency seek public input on 
38         extending and expanding the managed care pilot program 
39         and post certain information on its website; amending 
40         s. 409.9122, F.S.; providing that time allotted to any 
41         Medicaid recipient for the selection of, enrollment 
42         in, or disenrollment from a managed care plan or 
43         MediPass is tolled throughout any month in which the 
44         enrollment broker or choice counseling provider 
45         adversely affects a beneficiary’s ability to access 
46         choice counseling or enrollment broker services by its 
47         failure to comply with the terms and conditions of its 
48         contract with the agency or has otherwise acted or 
49         failed to act in a manner that the agency deems likely 
50         to jeopardize its ability to perform certain assigned 
51         responsibilities; requiring the agency to incorporate 
52         certain provisions after a specified date in its 
53         contracts related to sanctions or fines for any action 
54         or the failure to act on the part of an enrollment 
55         broker or choice counselor provider; creating s. 
56         624.35, F.S.; providing a short title; creating s. 
57         624.351, F.S.; providing legislative intent; 
58         establishing the Medicaid and Public Assistance Fraud 
59         Strike Force within the Department of Financial 
60         Services to coordinate efforts to eliminate Medicaid 
61         and public assistance fraud; providing for membership; 
62         providing for meetings; specifying duties; requiring 
63         an annual report to the Legislature and Governor; 
64         creating s. 624.352, F.S.; directing the Chief 
65         Financial Officer to prepare model interagency 
66         agreements that address Medicaid and public assistance 
67         fraud; specifying which agencies can be a party to 
68         such agreements; amending s. 16.59, F.S.; conforming 
69         provisions to changes made by the act; requiring the 
70         Divisions of Insurance Fraud and Public Assistance 
71         Fraud in the Department of Financial Services to be 
72         collocated with the Medicaid Fraud Control Unit if 
73         possible; requiring positions dedicated to Medicaid 
74         managed care fraud to be collocated with the Division 
75         of Insurance Fraud; amending s. 20.121, F.S.; 
76         establishing the Division of Public Assistance Fraud 
77         within the Department of Financial Services; amending 
78         ss. 411.01, 414.33, and 414.39, F.S.; conforming 
79         provisions to changes made by the act; transferring, 
80         renumbering, and amending s. 943.401, F.S.; directing 
81         the Department of Financial Services rather than the 
82         Department of Law Enforcement to investigate public 
83         assistance fraud; directing the Auditor General and 
84         the Office of Program Policy Analysis and Government 
85         Accountability to review the Medicaid fraud and abuse 
86         processes in the Agency for Health Care 
87         Administration; requiring a report to the Legislature 
88         and Governor by a certain date; establishing the 
89         Medicaid claims adjudication project in the Agency for 
90         Health Care Administration to decrease the incidence 
91         of inaccurate payments and to improve the efficiency 
92         of the Medicaid claims processing system; transferring 
93         activities relating to public assistance fraud from 
94         the Department of Law Enforcement to the Division of 
95         Public Assistance Fraud in the Department of Financial 
96         Services by a type two transfer; providing effective 
97         dates. 
98 
99         WHEREAS, Florida’s Medicaid program is one of the largest 
100  in the country, serving approximately 2.7 million persons each 
101  month. The program provides health care benefits to families and 
102  individuals below certain income and resource levels. For the 
103  2008-2009 fiscal year, the Legislature appropriated $18.81 
104  billion to operate the Medicaid program which is funded from 
105  general revenue, trust funds that include federal matching 
106  funds, and other state funds, and 
107         WHEREAS, Medicaid fraud in Florida is epidemic, far 
108  reaching, and costs the state and the Federal Government 
109  billions of dollars annually. Medicaid fraud not only drives up 
110  the cost of health care and reduces the availability of funds to 
111  support needed services, but undermines the long-term solvency 
112  of both health care providers and the state’s Medicaid program, 
113  and 
114         WHEREAS, the state’s public assistance programs serve 
115  approximately 1.8 million Floridians each month by providing 
116  benefits for food, cash assistance for needy families, home 
117  health care for disabled adults, and grants to individuals and 
118  communities affected by natural disasters. For the 2008-2009 
119  fiscal year, the Legislature appropriated $626 million to 
120  operate public assistance programs, and 
121         WHEREAS, public assistance fraud costs taxpayers millions 
122  of dollars annually, which significantly and negatively impacts 
123  the various assistance programs by taking dollars that could be 
124  used to provide services for those people who have a legitimate 
125  need for assistance, and 
126         WHEREAS, both Medicaid and public assistance programs are 
127  vulnerable to fraudulent practices that can take many forms. For 
128  Medicaid, these practices range from providers who bill for 
129  services never rendered and who pay kickbacks to other providers 
130  for client referrals, to fraud occurring at the corporate level 
131  of a managed care organization. Fraudulent practices involving 
132  public assistance involve persons not disclosing material facts 
133  when obtaining assistance or not disclosing changes in 
134  circumstances while on public assistance, and 
135         WHEREAS, ridding the system of perpetrators who prey on the 
136  state’s Medicaid and public assistance programs helps reduce the 
137  state’s skyrocketing costs, makes more funds available for 
138  essential services, and improves the quality of care and the 
139  health status of our residents, and 
140         WHEREAS, aggressive and comprehensive measures are needed 
141  at the state level to investigate and prosecute Medicaid and 
142  public assistance fraud and to recover dollars stolen from these 
143  programs, and 
144         WHEREAS, new statewide initiatives and coordinated efforts 
145  are necessary to focus resources in order to aid law enforcement 
146  and investigative agencies in detecting and deterring this type 
147  of fraudulent activity, NOW, THEREFORE, 
148 
149  Be It Enacted by the Legislature of the State of Florida: 
150 
151         Section 1. Paragraph (b) of subsection (4) of section 
152  409.912, Florida Statutes, is amended, paragraph (d) of 
153  subsection (4) of that section is reenacted, present subsections 
154  (23) through (53) of that section are renumbered as subsections 
155  (24) through (54), respectively, a new subsection (23) is added 
156  to that section, and present subsections (21) and (22) of that 
157  section are amended, to read: 
158         409.912 Cost-effective purchasing of health care.—The 
159  agency shall purchase goods and services for Medicaid recipients 
160  in the most cost-effective manner consistent with the delivery 
161  of quality medical care. To ensure that medical services are 
162  effectively utilized, the agency may, in any case, require a 
163  confirmation or second physician’s opinion of the correct 
164  diagnosis for purposes of authorizing future services under the 
165  Medicaid program. This section does not restrict access to 
166  emergency services or poststabilization care services as defined 
167  in 42 C.F.R. part 438.114. Such confirmation or second opinion 
168  shall be rendered in a manner approved by the agency. The agency 
169  shall maximize the use of prepaid per capita and prepaid 
170  aggregate fixed-sum basis services when appropriate and other 
171  alternative service delivery and reimbursement methodologies, 
172  including competitive bidding pursuant to s. 287.057, designed 
173  to facilitate the cost-effective purchase of a case-managed 
174  continuum of care. The agency shall also require providers to 
175  minimize the exposure of recipients to the need for acute 
176  inpatient, custodial, and other institutional care and the 
177  inappropriate or unnecessary use of high-cost services. The 
178  agency shall contract with a vendor to monitor and evaluate the 
179  clinical practice patterns of providers in order to identify 
180  trends that are outside the normal practice patterns of a 
181  provider’s professional peers or the national guidelines of a 
182  provider’s professional association. The vendor must be able to 
183  provide information and counseling to a provider whose practice 
184  patterns are outside the norms, in consultation with the agency, 
185  to improve patient care and reduce inappropriate utilization. 
186  The agency may mandate prior authorization, drug therapy 
187  management, or disease management participation for certain 
188  populations of Medicaid beneficiaries, certain drug classes, or 
189  particular drugs to prevent fraud, abuse, overuse, and possible 
190  dangerous drug interactions. The Pharmaceutical and Therapeutics 
191  Committee shall make recommendations to the agency on drugs for 
192  which prior authorization is required. The agency shall inform 
193  the Pharmaceutical and Therapeutics Committee of its decisions 
194  regarding drugs subject to prior authorization. The agency is 
195  authorized to limit the entities it contracts with or enrolls as 
196  Medicaid providers by developing a provider network through 
197  provider credentialing. The agency may competitively bid single 
198  source-provider contracts if procurement of goods or services 
199  results in demonstrated cost savings to the state without 
200  limiting access to care. The agency may limit its network based 
201  on the assessment of beneficiary access to care, provider 
202  availability, provider quality standards, time and distance 
203  standards for access to care, the cultural competence of the 
204  provider network, demographic characteristics of Medicaid 
205  beneficiaries, practice and provider-to-beneficiary standards, 
206  appointment wait times, beneficiary use of services, provider 
207  turnover, provider profiling, provider licensure history, 
208  previous program integrity investigations and findings, peer 
209  review, provider Medicaid policy and billing compliance records, 
210  clinical and medical record audits, and other factors. Providers 
211  shall not be entitled to enrollment in the Medicaid provider 
212  network. The agency shall determine instances in which allowing 
213  Medicaid beneficiaries to purchase durable medical equipment and 
214  other goods is less expensive to the Medicaid program than long 
215  term rental of the equipment or goods. The agency may establish 
216  rules to facilitate purchases in lieu of long-term rentals in 
217  order to protect against fraud and abuse in the Medicaid program 
218  as defined in s. 409.913. The agency may seek federal waivers 
219  necessary to administer these policies. 
220         (4) The agency may contract with: 
221         (b) An entity that is providing comprehensive behavioral 
222  health care services to certain Medicaid recipients through a 
223  capitated, prepaid arrangement pursuant to the federal waiver 
224  provided for by s. 409.905(5). Such entity must be licensed 
225  under chapter 624, chapter 636, or chapter 641, or authorized 
226  under paragraph (c) or paragraph (d), and must possess the 
227  clinical systems and operational competence to manage risk and 
228  provide comprehensive behavioral health care to Medicaid 
229  recipients. As used in this paragraph, the term “comprehensive 
230  behavioral health care services” means covered mental health and 
231  substance abuse treatment services that are available to 
232  Medicaid recipients. The secretary of the Department of Children 
233  and Family Services shall approve provisions of procurements 
234  related to children in the department’s care or custody before 
235  enrolling such children in a prepaid behavioral health plan. Any 
236  contract awarded under this paragraph must be competitively 
237  procured. In developing the behavioral health care prepaid plan 
238  procurement document, the agency shall ensure that the 
239  procurement document requires the contractor to develop and 
240  implement a plan to ensure compliance with s. 394.4574 related 
241  to services provided to residents of licensed assisted living 
242  facilities that hold a limited mental health license. Except as 
243  provided in subparagraph 8., and except in counties where the 
244  Medicaid managed care pilot program is authorized pursuant to s. 
245  409.91211, the agency shall seek federal approval to contract 
246  with a single entity meeting these requirements to provide 
247  comprehensive behavioral health care services to all Medicaid 
248  recipients not enrolled in a Medicaid managed care plan 
249  authorized under s. 409.91211, a provider service network 
250  authorized under paragraph (d), or a Medicaid health maintenance 
251  organization in an AHCA area. In an AHCA area where the Medicaid 
252  managed care pilot program is authorized pursuant to s. 
253  409.91211 in one or more counties, the agency may procure a 
254  contract with a single entity to serve the remaining counties as 
255  an AHCA area or the remaining counties may be included with an 
256  adjacent AHCA area and are subject to this paragraph. Each 
257  entity must offer a sufficient choice of providers in its 
258  network to ensure recipient access to care and the opportunity 
259  to select a provider with whom they are satisfied. The network 
260  shall include all public mental health hospitals. To ensure 
261  unimpaired access to behavioral health care services by Medicaid 
262  recipients, all contracts issued pursuant to this paragraph must 
263  require 80 percent of the capitation paid to the managed care 
264  plan, including health maintenance organizations and capitated 
265  provider service networks, to be expended for the provision of 
266  behavioral health care services. If the managed care plan 
267  expends less than 80 percent of the capitation paid for the 
268  provision of behavioral health care services, the difference 
269  shall be returned to the agency. The agency shall provide the 
270  plan with a certification letter indicating the amount of 
271  capitation paid during each calendar year for behavioral health 
272  care services pursuant to this section. The agency may reimburse 
273  for substance abuse treatment services on a fee-for-service 
274  basis until the agency finds that adequate funds are available 
275  for capitated, prepaid arrangements. 
276         1. By January 1, 2001, the agency shall modify the 
277  contracts with the entities providing comprehensive inpatient 
278  and outpatient mental health care services to Medicaid 
279  recipients in Hillsborough, Highlands, Hardee, Manatee, and Polk 
280  Counties, to include substance abuse treatment services. 
281         2. By July 1, 2003, the agency and the Department of 
282  Children and Family Services shall execute a written agreement 
283  that requires collaboration and joint development of all policy, 
284  budgets, procurement documents, contracts, and monitoring plans 
285  that have an impact on the state and Medicaid community mental 
286  health and targeted case management programs. 
287         3. Except as provided in subparagraph 8., by July 1, 2006, 
288  the agency and the Department of Children and Family Services 
289  shall contract with managed care entities in each AHCA area 
290  except area 6 or arrange to provide comprehensive inpatient and 
291  outpatient mental health and substance abuse services through 
292  capitated prepaid arrangements to all Medicaid recipients who 
293  are eligible to participate in such plans under federal law and 
294  regulation. In AHCA areas where eligible individuals number less 
295  than 150,000, the agency shall contract with a single managed 
296  care plan to provide comprehensive behavioral health services to 
297  all recipients who are not enrolled in a Medicaid health 
298  maintenance organization, a provider service network authorized 
299  under paragraph (d), or a Medicaid capitated managed care plan 
300  authorized under s. 409.91211. The agency may contract with more 
301  than one comprehensive behavioral health provider to provide 
302  care to recipients who are not enrolled in a Medicaid capitated 
303  managed care plan authorized under s. 409.91211, a provider 
304  service network authorized under paragraph (d), or a Medicaid 
305  health maintenance organization in AHCA areas where the eligible 
306  population exceeds 150,000. In an AHCA area where the Medicaid 
307  managed care pilot program is authorized pursuant to s. 
308  409.91211 in one or more counties, the agency may procure a 
309  contract with a single entity to serve the remaining counties as 
310  an AHCA area or the remaining counties may be included with an 
311  adjacent AHCA area and shall be subject to this paragraph. 
312  Contracts for comprehensive behavioral health providers awarded 
313  pursuant to this section shall be competitively procured. Both 
314  for-profit and not-for-profit corporations are eligible to 
315  compete. Managed care plans contracting with the agency under 
316  subsection (3) or paragraph (d), shall provide and receive 
317  payment for the same comprehensive behavioral health benefits as 
318  provided in AHCA rules, including handbooks incorporated by 
319  reference. In AHCA area 11, the agency shall contract with at 
320  least two comprehensive behavioral health care providers to 
321  provide behavioral health care to recipients in that area who 
322  are enrolled in, or assigned to, the MediPass program. One of 
323  the behavioral health care contracts must be with the existing 
324  provider service network pilot project, as described in 
325  paragraph (d), for the purpose of demonstrating the cost 
326  effectiveness of the provision of quality mental health services 
327  through a public hospital-operated managed care model. Payment 
328  shall be at an agreed-upon capitated rate to ensure cost 
329  savings. Of the recipients in area 11 who are assigned to 
330  MediPass under s. 409.9122(2)(k), a minimum of 50,000 of those 
331  MediPass-enrolled recipients shall be assigned to the existing 
332  provider service network in area 11 for their behavioral care. 
333         4. By October 1, 2003, the agency and the department shall 
334  submit a plan to the Governor, the President of the Senate, and 
335  the Speaker of the House of Representatives which provides for 
336  the full implementation of capitated prepaid behavioral health 
337  care in all areas of the state. 
338         a. Implementation shall begin in 2003 in those AHCA areas 
339  of the state where the agency is able to establish sufficient 
340  capitation rates. 
341         b. If the agency determines that the proposed capitation 
342  rate in any area is insufficient to provide appropriate 
343  services, the agency may adjust the capitation rate to ensure 
344  that care will be available. The agency and the department may 
345  use existing general revenue to address any additional required 
346  match but may not over-obligate existing funds on an annualized 
347  basis. 
348         c. Subject to any limitations provided in the General 
349  Appropriations Act, the agency, in compliance with appropriate 
350  federal authorization, shall develop policies and procedures 
351  that allow for certification of local and state funds. 
352         5. Children residing in a statewide inpatient psychiatric 
353  program, or in a Department of Juvenile Justice or a Department 
354  of Children and Family Services residential program approved as 
355  a Medicaid behavioral health overlay services provider may not 
356  be included in a behavioral health care prepaid health plan or 
357  any other Medicaid managed care plan pursuant to this paragraph. 
358         6. In converting to a prepaid system of delivery, the 
359  agency shall in its procurement document require an entity 
360  providing only comprehensive behavioral health care services to 
361  prevent the displacement of indigent care patients by enrollees 
362  in the Medicaid prepaid health plan providing behavioral health 
363  care services from facilities receiving state funding to provide 
364  indigent behavioral health care, to facilities licensed under 
365  chapter 395 which do not receive state funding for indigent 
366  behavioral health care, or reimburse the unsubsidized facility 
367  for the cost of behavioral health care provided to the displaced 
368  indigent care patient. 
369         7. Traditional community mental health providers under 
370  contract with the Department of Children and Family Services 
371  pursuant to part IV of chapter 394, child welfare providers 
372  under contract with the Department of Children and Family 
373  Services in areas 1 and 6, and inpatient mental health providers 
374  licensed pursuant to chapter 395 must be offered an opportunity 
375  to accept or decline a contract to participate in any provider 
376  network for prepaid behavioral health services. 
377         8. All Medicaid-eligible children, except children in area 
378  1 and children in Highlands County, Hardee County, Polk County, 
379  or Manatee County of area 6, that are open for child welfare 
380  services in the HomeSafeNet system, shall receive their 
381  behavioral health care services through a specialty prepaid plan 
382  operated by community-based lead agencies through a single 
383  agency or formal agreements among several agencies. The 
384  specialty prepaid plan must result in savings to the state 
385  comparable to savings achieved in other Medicaid managed care 
386  and prepaid programs. Such plan must provide mechanisms to 
387  maximize state and local revenues. The specialty prepaid plan 
388  shall be developed by the agency and the Department of Children 
389  and Family Services. The agency may seek federal waivers to 
390  implement this initiative. Medicaid-eligible children whose 
391  cases are open for child welfare services in the HomeSafeNet 
392  system and who reside in AHCA area 10 are exempt from the 
393  specialty prepaid plan upon the development of a service 
394  delivery mechanism for children who reside in area 10 as 
395  specified in s. 409.91211(3)(dd). 
396         (d) A provider service network may be reimbursed on a fee 
397  for-service or prepaid basis. A provider service network which 
398  is reimbursed by the agency on a prepaid basis shall be exempt 
399  from parts I and III of chapter 641, but must comply with the 
400  solvency requirements in s. 641.2261(2) and meet appropriate 
401  financial reserve, quality assurance, and patient rights 
402  requirements as established by the agency. Medicaid recipients 
403  assigned to a provider service network shall be chosen equally 
404  from those who would otherwise have been assigned to prepaid 
405  plans and MediPass. The agency is authorized to seek federal 
406  Medicaid waivers as necessary to implement the provisions of 
407  this section. Any contract previously awarded to a provider 
408  service network operated by a hospital pursuant to this 
409  subsection shall remain in effect for a period of 3 years 
410  following the current contract expiration date, regardless of 
411  any contractual provisions to the contrary. A provider service 
412  network is a network established or organized and operated by a 
413  health care provider, or group of affiliated health care 
414  providers, including minority physician networks and emergency 
415  room diversion programs that meet the requirements of s. 
416  409.91211, which provides a substantial proportion of the health 
417  care items and services under a contract directly through the 
418  provider or affiliated group of providers and may make 
419  arrangements with physicians or other health care professionals, 
420  health care institutions, or any combination of such individuals 
421  or institutions to assume all or part of the financial risk on a 
422  prospective basis for the provision of basic health services by 
423  the physicians, by other health professionals, or through the 
424  institutions. The health care providers must have a controlling 
425  interest in the governing body of the provider service network 
426  organization. 
427         (21) Any entity contracting with the agency pursuant to 
428  this section to provide health care services to Medicaid 
429  recipients is prohibited from engaging in any of the following 
430  practices or activities: 
431         (a) Practices that are discriminatory, including, but not 
432  limited to, attempts to discourage participation on the basis of 
433  actual or perceived health status. 
434         (b) Activities that could mislead or confuse recipients, or 
435  misrepresent the organization, its marketing representatives, or 
436  the agency. Violations of this paragraph include, but are not 
437  limited to: 
438         1. False or misleading claims that marketing 
439  representatives are employees or representatives of the state or 
440  county, or of anyone other than the entity or the organization 
441  by whom they are reimbursed. 
442         2. False or misleading claims that the entity is 
443  recommended or endorsed by any state or county agency, or by any 
444  other organization which has not certified its endorsement in 
445  writing to the entity. 
446         3. False or misleading claims that the state or county 
447  recommends that a Medicaid recipient enroll with an entity. 
448         4. Claims that a Medicaid recipient will lose benefits 
449  under the Medicaid program, or any other health or welfare 
450  benefits to which the recipient is legally entitled, if the 
451  recipient does not enroll with the entity. 
452         (c) Granting or offering of any monetary or other valuable 
453  consideration for enrollment, except as authorized by subsection 
454  (25) (24). 
455         (d) Door-to-door solicitation of recipients who have not 
456  contacted the entity or who have not invited the entity to make 
457  a presentation. 
458         (e) Solicitation of Medicaid recipients by marketing 
459  representatives stationed in state offices unless approved and 
460  supervised by the agency or its agent and approved by the 
461  affected state agency when solicitation occurs in an office of 
462  the state agency. The agency shall ensure that marketing 
463  representatives stationed in state offices shall market their 
464  managed care plans to Medicaid recipients only in designated 
465  areas and in such a way as to not interfere with the recipients’ 
466  activities in the state office. 
467         (f) Enrollment of Medicaid recipients. 
468         (22) The agency shall may impose a fine for a violation of 
469  this section or the contract with the agency by a person or 
470  entity that is under contract with the agency. With respect to 
471  any nonwillful violation, such fine shall not exceed $2,500 per 
472  violation. In no event shall such fine exceed an aggregate 
473  amount of $10,000 for all nonwillful violations arising out of 
474  the same action. With respect to any knowing and willful 
475  violation of this section or the contract with the agency, the 
476  agency may impose a fine upon the entity in an amount not to 
477  exceed $20,000 for each such violation. In no event shall such 
478  fine exceed an aggregate amount of $100,000 for all knowing and 
479  willful violations arising out of the same action. 
480         (23) Any entity that contracts with the agency on a prepaid 
481  or fixed-sum basis as a managed care plan as defined in s. 
482  409.9122(2)(f) or s. 409.91211 shall post a surety bond with the 
483  agency in an amount that is equivalent to a 1-year guaranteed 
484  savings amount as specified in the contract. In lieu of a surety 
485  bond, the agency may establish an irrevocable account in which 
486  the vendor funds an equivalent amount over a 6-month period. The 
487  purpose of the surety bond or account is to protect the agency 
488  if the entity terminates its contract with the agency before the 
489  scheduled end date for the contract. If the contract is 
490  terminated by the vendor for any reason, the agency shall pursue 
491  a claim against the surety bond or account for an early 
492  termination fee. The early termination fee must be equal to 
493  administrative costs incurred by the state due to the early 
494  termination and the differential of the guaranteed savings based 
495  on the original contract term and the corresponding termination 
496  date. The agency shall terminate a vendor who does not reimburse 
497  the state within 30 days after any early termination involving 
498  administrative costs and requiring reimbursement of lost savings 
499  from the Medicaid program. 
500         Section 2. Subsections (1) through (6) of section 
501  409.91211, Florida Statutes, are amended to read: 
502         409.91211 Medicaid managed care pilot program.— 
503         (1)(a) The agency is authorized to seek and implement 
504  experimental, pilot, or demonstration project waivers, pursuant 
505  to s. 1115 of the Social Security Act, to create a statewide 
506  initiative to provide for a more efficient and effective service 
507  delivery system that enhances quality of care and client 
508  outcomes in the Florida Medicaid program pursuant to this 
509  section. Phase one of the demonstration shall be implemented in 
510  two geographic areas. One demonstration site shall include only 
511  Broward County. A second demonstration site shall initially 
512  include Duval County and shall be expanded to include Baker, 
513  Clay, and Nassau Counties within 1 year after the Duval County 
514  program becomes operational. The agency shall implement 
515  expansion of the program to include the remaining counties of 
516  the state and remaining eligibility groups in accordance with 
517  the process specified in the federally approved special terms 
518  and conditions numbered 11-W-00206/4, as approved by the federal 
519  Centers for Medicare and Medicaid Services on October 19, 2005, 
520  with a goal of full statewide implementation by June 30, 2014 
521  2011. 
522         (b) This waiver extension shall authority is contingent 
523  upon federal approval to preserve the low-income pool upper 
524  payment-limit funding mechanism for providers and hospitals, 
525  including a guarantee of a reasonable growth factor, a 
526  methodology to allow the use of a portion of these funds to 
527  serve as a risk pool for demonstration sites, provisions to 
528  preserve the state’s ability to use intergovernmental transfers, 
529  and provisions to protect the disproportionate share program 
530  authorized pursuant to this chapter. Upon completion of the 
531  evaluation conducted under s. 3, ch. 2005-133, Laws of Florida, 
532  The agency shall expand may request statewide expansion of the 
533  demonstration to counties that have two or more plans and that 
534  have capacity to serve the designated population projects. The 
535  agency may expand to additional counties as plan capacity is 
536  developed. Statewide phase-in to additional counties shall be 
537  contingent upon review and approval by the Legislature. Under 
538  the upper-payment-limit program, or the low-income pool as 
539  implemented by the Agency for Health Care Administration 
540  pursuant to federal waiver, the state matching funds required 
541  for the program shall be provided by local governmental entities 
542  through intergovernmental transfers in accordance with published 
543  federal statutes and regulations. The Agency for Health Care 
544  Administration shall distribute upper-payment-limit, 
545  disproportionate share hospital, and low-income pool funds 
546  according to published federal statutes, regulations, and 
547  waivers and the low-income pool methodology approved by the 
548  federal Centers for Medicare and Medicaid Services. 
549         (c) It is the intent of the Legislature that the low-income 
550  pool plan required by the terms and conditions of the Medicaid 
551  reform waiver and submitted to the federal Centers for Medicare 
552  and Medicaid Services propose the distribution of the above 
553  mentioned program funds based on the following objectives: 
554         1. Assure a broad and fair distribution of available funds 
555  based on the access provided by Medicaid participating 
556  hospitals, regardless of their ownership status, through their 
557  delivery of inpatient or outpatient care for Medicaid 
558  beneficiaries and uninsured and underinsured individuals; 
559         2. Assure accessible emergency inpatient and outpatient 
560  care for Medicaid beneficiaries and uninsured and underinsured 
561  individuals; 
562         3. Enhance primary, preventive, and other ambulatory care 
563  coverages for uninsured individuals; 
564         4. Promote teaching and specialty hospital programs; 
565         5. Promote the stability and viability of statutorily 
566  defined rural hospitals and hospitals that serve as sole 
567  community hospitals; 
568         6. Recognize the extent of hospital uncompensated care 
569  costs; 
570         7. Maintain and enhance essential community hospital care; 
571         8. Maintain incentives for local governmental entities to 
572  contribute to the cost of uncompensated care; 
573         9. Promote measures to avoid preventable hospitalizations; 
574         10. Account for hospital efficiency; and 
575         11. Contribute to a community’s overall health system. 
576         (2) The Legislature intends for the capitated managed care 
577  pilot program to: 
578         (a) Provide recipients in Medicaid fee-for-service or the 
579  MediPass program a comprehensive and coordinated capitated 
580  managed care system for all health care services specified in 
581  ss. 409.905 and 409.906. 
582         (b) Stabilize Medicaid expenditures under the pilot program 
583  compared to Medicaid expenditures in the pilot area for the 3 
584  years before implementation of the pilot program, while 
585  ensuring: 
586         1. Consumer education and choice. 
587         2. Access to medically necessary services. 
588         3. Coordination of preventative, acute, and long-term care. 
589         4. Reductions in unnecessary service utilization. 
590         (c) Provide an opportunity to evaluate the feasibility of 
591  statewide implementation of capitated managed care networks as a 
592  replacement for the current Medicaid fee-for-service and 
593  MediPass systems. 
594         (3) The agency shall have the following powers, duties, and 
595  responsibilities with respect to the pilot program: 
596         (a) To implement a system to deliver all mandatory services 
597  specified in s. 409.905 and optional services specified in s. 
598  409.906, as approved by the Centers for Medicare and Medicaid 
599  Services and the Legislature in the waiver pursuant to this 
600  section. Services to recipients under plan benefits shall 
601  include emergency services provided under s. 409.9128. 
602         (b) To implement a pilot program, including Medicaid 
603  eligibility categories specified in ss. 409.903 and 409.904, as 
604  authorized in an approved federal waiver. 
605         (c) To implement the managed care pilot program that 
606  maximizes all available state and federal funds, including those 
607  obtained through intergovernmental transfers, the low-income 
608  pool, supplemental Medicaid payments, and the disproportionate 
609  share program. Within the parameters allowed by federal statute 
610  and rule, the agency may seek options for making direct payments 
611  to hospitals and physicians employed by or under contract with 
612  the state’s medical schools for the costs associated with 
613  graduate medical education under Medicaid reform. 
614         (d) To implement actuarially sound, risk-adjusted 
615  capitation rates for Medicaid recipients in the pilot program 
616  which cover comprehensive care, enhanced services, and 
617  catastrophic care. 
618         (e) To implement policies and guidelines for phasing in 
619  financial risk for approved provider service networks that, for 
620  purposes of this paragraph, include the Children’s Medical 
621  Services Network, over a 5-year period. These policies and 
622  guidelines must include an option for a provider service network 
623  to be paid fee-for-service rates. For any provider service 
624  network established in a managed care pilot area, the option to 
625  be paid fee-for-service rates must include a savings-settlement 
626  mechanism that is consistent with s. 409.912(44). This model 
627  must be converted to a risk-adjusted capitated rate by the 
628  beginning of the sixth year of operation, and may be converted 
629  earlier at the option of the provider service network. Federally 
630  qualified health centers may be offered an opportunity to accept 
631  or decline a contract to participate in any provider network for 
632  prepaid primary care services. 
633         (f) To implement stop-loss requirements and the transfer of 
634  excess cost to catastrophic coverage that accommodates the risks 
635  associated with the development of the pilot program. 
636         (g) To recommend a process to be used by the Social 
637  Services Estimating Conference to determine and validate the 
638  rate of growth of the per-member costs of providing Medicaid 
639  services under the managed care pilot program. 
640         (h) To implement program standards and credentialing 
641  requirements for capitated managed care networks to participate 
642  in the pilot program, including those related to fiscal 
643  solvency, quality of care, and adequacy of access to health care 
644  providers. It is the intent of the Legislature that, to the 
645  extent possible, any pilot program authorized by the state under 
646  this section include any federally qualified health center, 
647  federally qualified rural health clinic, county health 
648  department, the Children’s Medical Services Network within the 
649  Department of Health, or other federally, state, or locally 
650  funded entity that serves the geographic areas within the 
651  boundaries of the pilot program that requests to participate. 
652  This paragraph does not relieve an entity that qualifies as a 
653  capitated managed care network under this section from any other 
654  licensure or regulatory requirements contained in state or 
655  federal law which would otherwise apply to the entity. The 
656  standards and credentialing requirements shall be based upon, 
657  but are not limited to: 
658         1. Compliance with the accreditation requirements as 
659  provided in s. 641.512. 
660         2. Compliance with early and periodic screening, diagnosis, 
661  and treatment screening requirements under federal law. 
662         3. The percentage of voluntary disenrollments. 
663         4. Immunization rates. 
664         5. Standards of the National Committee for Quality 
665  Assurance and other approved accrediting bodies. 
666         6. Recommendations of other authoritative bodies. 
667         7. Specific requirements of the Medicaid program, or 
668  standards designed to specifically meet the unique needs of 
669  Medicaid recipients. 
670         8. Compliance with the health quality improvement system as 
671  established by the agency, which incorporates standards and 
672  guidelines developed by the Centers for Medicare and Medicaid 
673  Services as part of the quality assurance reform initiative. 
674         9. The network’s infrastructure capacity to manage 
675  financial transactions, recordkeeping, data collection, and 
676  other administrative functions. 
677         10. The network’s ability to submit any financial, 
678  programmatic, or patient-encounter data or other information 
679  required by the agency to determine the actual services provided 
680  and the cost of administering the plan. 
681         (i) To implement a mechanism for providing information to 
682  Medicaid recipients for the purpose of selecting a capitated 
683  managed care plan. For each plan available to a recipient, the 
684  agency, at a minimum, shall ensure that the recipient is 
685  provided with: 
686         1. A list and description of the benefits provided. 
687         2. Information about cost sharing. 
688         3. A list of providers participating in the plan networks. 
689         4.3. Plan performance data, if available. 
690         4. An explanation of benefit limitations. 
691         5. Contact information, including identification of 
692  providers participating in the network, geographic locations, 
693  and transportation limitations. 
694         6. Any other information the agency determines would 
695  facilitate a recipient’s understanding of the plan or insurance 
696  that would best meet his or her needs. 
697         (j) To implement a system to ensure that there is a record 
698  of recipient acknowledgment that plan choice counseling has been 
699  provided. 
700         (k) To implement a choice counseling system to ensure that 
701  the choice counseling process and related material are designed 
702  to provide counseling through face-to-face interaction, by 
703  telephone or, and in writing and through other forms of relevant 
704  media. Materials shall be written at the fourth-grade reading 
705  level and available in a language other than English when 5 
706  percent of the county speaks a language other than English. 
707  Choice counseling shall also use language lines and other 
708  services for impaired recipients, such as TTD/TTY. 
709         (l) To implement a system that prohibits capitated managed 
710  care plans, their representatives, and providers employed by or 
711  contracted with the capitated managed care plans from recruiting 
712  persons eligible for or enrolled in Medicaid, from providing 
713  inducements to Medicaid recipients to select a particular 
714  capitated managed care plan, and from prejudicing Medicaid 
715  recipients against other capitated managed care plans. The 
716  system shall require the entity performing choice counseling to 
717  determine if the recipient has made a choice of a plan or has 
718  opted out because of duress, threats, payment to the recipient, 
719  or incentives promised to the recipient by a third party. If the 
720  choice counseling entity determines that the decision to choose 
721  a plan was unlawfully influenced or a plan violated any of the 
722  provisions of s. 409.912(21), the choice counseling entity shall 
723  immediately report the violation to the agency’s program 
724  integrity section for investigation. Verification of choice 
725  counseling by the recipient shall include a stipulation that the 
726  recipient acknowledges the provisions of this subsection. 
727         (m) To implement a choice counseling system that promotes 
728  health literacy, uses technology effectively, and provides 
729  information intended aimed to reduce minority health disparities 
730  through outreach activities for Medicaid recipients. 
731         (n) To contract with entities to perform choice counseling. 
732  The agency may establish standards and performance contracts, 
733  including standards requiring the contractor to hire choice 
734  counselors who are representative of the state’s diverse 
735  population and to train choice counselors in working with 
736  culturally diverse populations. 
737         (o) To implement eligibility assignment processes to 
738  facilitate client choice while ensuring pilot programs of 
739  adequate enrollment levels. These processes shall ensure that 
740  pilot sites have sufficient levels of enrollment to conduct a 
741  valid test of the managed care pilot program within a 2-year 
742  timeframe. 
743         (p) To implement standards for plan compliance, including, 
744  but not limited to, standards for quality assurance and 
745  performance improvement, standards for peer or professional 
746  reviews, grievance policies, and policies for maintaining 
747  program integrity. The agency shall develop a data-reporting 
748  system, seek input from managed care plans in order to establish 
749  requirements for patient-encounter reporting, and ensure that 
750  the data reported is accurate and complete. 
751         1. In performing the duties required under this section, 
752  the agency shall work with managed care plans to establish a 
753  uniform system to measure and monitor outcomes for a recipient 
754  of Medicaid services. 
755         2. The system shall use financial, clinical, and other 
756  criteria based on pharmacy, medical services, and other data 
757  that is related to the provision of Medicaid services, 
758  including, but not limited to: 
759         a. The Health Plan Employer Data and Information Set 
760  (HEDIS) or measures that are similar to HEDIS. 
761         b. Member satisfaction. 
762         c. Provider satisfaction. 
763         d. Report cards on plan performance and best practices. 
764         e. Compliance with the requirements for prompt payment of 
765  claims under ss. 627.613, 641.3155, and 641.513. 
766         f. Utilization and quality data for the purpose of ensuring 
767  access to medically necessary services, including 
768  underutilization or inappropriate denial of services. 
769         3. The agency shall require the managed care plans that 
770  have contracted with the agency to establish a quality assurance 
771  system that incorporates the provisions of s. 409.912(27) and 
772  any standards, rules, and guidelines developed by the agency. 
773         4. The agency shall establish an encounter database in 
774  order to compile data on health services rendered by health care 
775  practitioners who provide services to patients enrolled in 
776  managed care plans in the demonstration sites. The encounter 
777  database shall: 
778         a. Collect the following for each type of patient encounter 
779  with a health care practitioner or facility, including: 
780         (I) The demographic characteristics of the patient. 
781         (II) The principal, secondary, and tertiary diagnosis. 
782         (III) The procedure performed. 
783         (IV) The date and location where the procedure was 
784  performed. 
785         (V) The payment for the procedure, if any. 
786         (VI) If applicable, the health care practitioner’s 
787  universal identification number. 
788         (VII) If the health care practitioner rendering the service 
789  is a dependent practitioner, the modifiers appropriate to 
790  indicate that the service was delivered by the dependent 
791  practitioner. 
792         b. Collect appropriate information relating to prescription 
793  drugs for each type of patient encounter. 
794         c. Collect appropriate information related to health care 
795  costs and utilization from managed care plans participating in 
796  the demonstration sites. 
797         5. To the extent practicable, when collecting the data the 
798  agency shall use a standardized claim form or electronic 
799  transfer system that is used by health care practitioners, 
800  facilities, and payors. 
801         6. Health care practitioners and facilities in the 
802  demonstration sites shall electronically submit, and managed 
803  care plans participating in the demonstration sites shall 
804  electronically receive, information concerning claims payments 
805  and any other information reasonably related to the encounter 
806  database using a standard format as required by the agency. 
807         7. The agency shall establish reasonable deadlines for 
808  phasing in the electronic transmittal of full encounter data. 
809         8. The system must ensure that the data reported is 
810  accurate and complete. 
811         (q) To implement a grievance resolution process for 
812  Medicaid recipients enrolled in a capitated managed care network 
813  under the pilot program modeled after the subscriber assistance 
814  panel, as created in s. 408.7056. This process shall include a 
815  mechanism for an expedited review of no greater than 24 hours 
816  after notification of a grievance if the life of a Medicaid 
817  recipient is in imminent and emergent jeopardy. 
818         (r) To implement a grievance resolution process for health 
819  care providers employed by or contracted with a capitated 
820  managed care network under the pilot program in order to settle 
821  disputes among the provider and the managed care network or the 
822  provider and the agency. 
823         (s) To implement criteria in an approved federal waiver to 
824  designate health care providers as eligible to participate in 
825  the pilot program. These criteria must include at a minimum 
826  those criteria specified in s. 409.907. 
827         (t) To use health care provider agreements for 
828  participation in the pilot program. 
829         (u) To require that all health care providers under 
830  contract with the pilot program be duly licensed in the state, 
831  if such licensure is available, and meet other criteria as may 
832  be established by the agency. These criteria shall include at a 
833  minimum those criteria specified in s. 409.907. 
834         (v) To ensure that managed care organizations work 
835  collaboratively with other state or local governmental programs 
836  or institutions for the coordination of health care to eligible 
837  individuals receiving services from such programs or 
838  institutions. 
839         (w) To implement procedures to minimize the risk of 
840  Medicaid fraud and abuse in all plans operating in the Medicaid 
841  managed care pilot program authorized in this section. 
842         1. The agency shall ensure that applicable provisions of 
843  this chapter and chapters 414, 626, 641, and 932 which relate to 
844  Medicaid fraud and abuse are applied and enforced at the 
845  demonstration project sites. 
846         2. Providers must have the certification, license, and 
847  credentials that are required by law and waiver requirements. 
848         3. The agency shall ensure that the plan is in compliance 
849  with s. 409.912(21) and (22). 
850         4. The agency shall require that each plan establish 
851  functions and activities governing program integrity in order to 
852  reduce the incidence of fraud and abuse. Plans must report 
853  instances of fraud and abuse pursuant to chapter 641. 
854         5. The plan shall have written administrative and 
855  management arrangements or procedures, including a mandatory 
856  compliance plan, which are designed to guard against fraud and 
857  abuse. The plan shall designate a compliance officer who has 
858  sufficient experience in health care. 
859         6.a. The agency shall require all managed care plan 
860  contractors in the pilot program to report all instances of 
861  suspected fraud and abuse. A failure to report instances of 
862  suspected fraud and abuse is a violation of law and subject to 
863  the penalties provided by law. 
864         b. An instance of fraud and abuse in the managed care plan, 
865  including, but not limited to, defrauding the state health care 
866  benefit program by misrepresentation of fact in reports, claims, 
867  certifications, enrollment claims, demographic statistics, or 
868  patient-encounter data; misrepresentation of the qualifications 
869  of persons rendering health care and ancillary services; bribery 
870  and false statements relating to the delivery of health care; 
871  unfair and deceptive marketing practices; and false claims 
872  actions in the provision of managed care, is a violation of law 
873  and subject to the penalties provided by law. 
874         c. The agency shall require that all contractors make all 
875  files and relevant billing and claims data accessible to state 
876  regulators and investigators and that all such data is linked 
877  into a unified system to ensure consistent reviews and 
878  investigations. 
879         (x) To develop and provide actuarial and benefit design 
880  analyses that indicate the effect on capitation rates and 
881  benefits offered in the pilot program over a prospective 5-year 
882  period based on the following assumptions: 
883         1. Growth in capitation rates which is limited to the 
884  estimated growth rate in general revenue. 
885         2. Growth in capitation rates which is limited to the 
886  average growth rate over the last 3 years in per-recipient 
887  Medicaid expenditures. 
888         3. Growth in capitation rates which is limited to the 
889  growth rate of aggregate Medicaid expenditures between the 2003 
890  2004 fiscal year and the 2004-2005 fiscal year. 
891         (y) To develop a mechanism to require capitated managed 
892  care plans to reimburse qualified emergency service providers, 
893  including, but not limited to, ambulance services, in accordance 
894  with ss. 409.908 and 409.9128. The pilot program must include a 
895  provision for continuing fee-for-service payments for emergency 
896  services, including, but not limited to, individuals who access 
897  ambulance services or emergency departments and who are 
898  subsequently determined to be eligible for Medicaid services. 
899         (z) To ensure that school districts participating in the 
900  certified school match program pursuant to ss. 409.908(21) and 
901  1011.70 shall be reimbursed by Medicaid, subject to the 
902  limitations of s. 1011.70(1), for a Medicaid-eligible child 
903  participating in the services as authorized in s. 1011.70, as 
904  provided for in s. 409.9071, regardless of whether the child is 
905  enrolled in a capitated managed care network. Capitated managed 
906  care networks must make a good faith effort to execute 
907  agreements with school districts regarding the coordinated 
908  provision of services authorized under s. 1011.70. County health 
909  departments and federally qualified health centers delivering 
910  school-based services pursuant to ss. 381.0056 and 381.0057 must 
911  be reimbursed by Medicaid for the federal share for a Medicaid 
912  eligible child who receives Medicaid-covered services in a 
913  school setting, regardless of whether the child is enrolled in a 
914  capitated managed care network. Capitated managed care networks 
915  must make a good faith effort to execute agreements with county 
916  health departments and federally qualified health centers 
917  regarding the coordinated provision of services to a Medicaid 
918  eligible child. To ensure continuity of care for Medicaid 
919  patients, the agency, the Department of Health, and the 
920  Department of Education shall develop procedures for ensuring 
921  that a student’s capitated managed care network provider 
922  receives information relating to services provided in accordance 
923  with ss. 381.0056, 381.0057, 409.9071, and 1011.70. 
924         (aa) To implement a mechanism whereby Medicaid recipients 
925  who are already enrolled in a managed care plan or the MediPass 
926  program in the pilot areas shall be offered the opportunity to 
927  change to capitated managed care plans on a staggered basis, as 
928  defined by the agency. All Medicaid recipients shall have 30 
929  days in which to make a choice of capitated managed care plans. 
930  Those Medicaid recipients who do not make a choice shall be 
931  assigned to a capitated managed care plan in accordance with 
932  paragraph (4)(a) and shall be exempt from s. 409.9122. To 
933  facilitate continuity of care for a Medicaid recipient who is 
934  also a recipient of Supplemental Security Income (SSI), prior to 
935  assigning the SSI recipient to a capitated managed care plan, 
936  the agency shall determine whether the SSI recipient has an 
937  ongoing relationship with a provider or capitated managed care 
938  plan, and, if so, the agency shall assign the SSI recipient to 
939  that provider or capitated managed care plan where feasible. 
940  Those SSI recipients who do not have such a provider 
941  relationship shall be assigned to a capitated managed care plan 
942  provider in accordance with paragraph (4)(a) and shall be exempt 
943  from s. 409.9122. 
944         (bb) To develop and recommend a service delivery 
945  alternative for children having chronic medical conditions which 
946  establishes a medical home project to provide primary care 
947  services to this population. The project shall provide 
948  community-based primary care services that are integrated with 
949  other subspecialties to meet the medical, developmental, and 
950  emotional needs for children and their families. This project 
951  shall include an evaluation component to determine impacts on 
952  hospitalizations, length of stays, emergency room visits, costs, 
953  and access to care, including specialty care and patient and 
954  family satisfaction. 
955         (cc) To develop and recommend service delivery mechanisms 
956  within capitated managed care plans to provide Medicaid services 
957  as specified in ss. 409.905 and 409.906 to persons with 
958  developmental disabilities sufficient to meet the medical, 
959  developmental, and emotional needs of these persons. 
960         (dd) To implement service delivery mechanisms within a 
961  specialty plan in area 10 capitated managed care plans to 
962  provide behavioral health care services Medicaid services as 
963  specified in ss. 409.905 and 409.906 to Medicaid-eligible 
964  children whose cases are open for child welfare services in the 
965  HomeSafeNet system. These services must be coordinated with 
966  community-based care providers as specified in s. 409.1671, 
967  where available, and be sufficient to meet the medical, 
968  developmental, behavioral, and emotional needs of these 
969  children. Children in area 10 who have an open case in the 
970  HomeSafeNet system shall be enrolled into the specialty plan. 
971  These service delivery mechanisms must be implemented no later 
972  than July 1, 2011 2008, in AHCA area 10 in order for the 
973  children in AHCA area 10 to remain exempt from the statewide 
974  plan under s. 409.912(4)(b)8. An administrative fee may be paid 
975  to the specialty plan for the coordination of services based on 
976  the receipt of the state share of that fee being provided 
977  through intergovernmental transfers. 
978         (4)(a) A Medicaid recipient in the pilot area who is not 
979  currently enrolled in a capitated managed care plan upon 
980  implementation is not eligible for services as specified in ss. 
981  409.905 and 409.906, for the amount of time that the recipient 
982  does not enroll in a capitated managed care network. If a 
983  Medicaid recipient has not enrolled in a capitated managed care 
984  plan within 30 days after eligibility, the agency shall assign 
985  the Medicaid recipient to a capitated managed care plan based on 
986  the assessed needs of the recipient as determined by the agency 
987  and the recipient shall be exempt from s. 409.9122. When making 
988  assignments, the agency shall take into account the following 
989  criteria: 
990         1. A capitated managed care network has sufficient network 
991  capacity to meet the needs of members. 
992         2. The capitated managed care network has previously 
993  enrolled the recipient as a member, or one of the capitated 
994  managed care network’s primary care providers has previously 
995  provided health care to the recipient. 
996         3. The agency has knowledge that the member has previously 
997  expressed a preference for a particular capitated managed care 
998  network as indicated by Medicaid fee-for-service claims data, 
999  but has failed to make a choice. 
1000         4. The capitated managed care network’s primary care 
1001  providers are geographically accessible to the recipient’s 
1002  residence. 
1003         5. Plan performance as designed by the agency. 
1004         (b) When more than one capitated managed care network 
1005  provider meets the criteria specified in paragraph (3)(h), the 
1006  agency shall make recipient assignments consecutively by family 
1007  unit. 
1008         (c) If a recipient is currently enrolled with a Medicaid 
1009  managed care organization that also operates an approved reform 
1010  plan within a demonstration area and the recipient fails to 
1011  choose a plan during the reform enrollment process or during 
1012  redetermination of eligibility, the recipient shall be 
1013  automatically assigned by the agency into the most appropriate 
1014  reform plan operated by the recipient’s current Medicaid managed 
1015  care plan. If the recipient’s current managed care plan does not 
1016  operate a reform plan in the demonstration area which adequately 
1017  meets the needs of the Medicaid recipient, the agency shall use 
1018  the automatic assignment process as prescribed in the special 
1019  terms and conditions numbered 11-W-00206/4. All enrollment and 
1020  choice counseling materials provided by the agency must contain 
1021  an explanation of the provisions of this paragraph for current 
1022  managed care recipients. 
1023         (d) Except for plan performance as provided for in 
1024  paragraph (a), the agency may not engage in practices that are 
1025  designed to favor one capitated managed care plan over another 
1026  or that are designed to influence Medicaid recipients to enroll 
1027  in a particular capitated managed care network in order to 
1028  strengthen its particular fiscal viability. 
1029         (e) After a recipient has made a selection or has been 
1030  enrolled in a capitated managed care network, the recipient 
1031  shall have 90 days in which to voluntarily disenroll and select 
1032  another capitated managed care network. After 90 days, no 
1033  further changes may be made except for cause. Cause shall 
1034  include, but not be limited to, poor quality of care, lack of 
1035  access to necessary specialty services, an unreasonable delay or 
1036  denial of service, inordinate or inappropriate changes of 
1037  primary care providers, service access impairments due to 
1038  significant changes in the geographic location of services, or 
1039  fraudulent enrollment. The agency may require a recipient to use 
1040  the capitated managed care network’s grievance process as 
1041  specified in paragraph (3)(q) prior to the agency’s 
1042  determination of cause, except in cases in which immediate risk 
1043  of permanent damage to the recipient’s health is alleged. The 
1044  grievance process, when used, must be completed in time to 
1045  permit the recipient to disenroll no later than the first day of 
1046  the second month after the month the disenrollment request was 
1047  made. If the capitated managed care network, as a result of the 
1048  grievance process, approves an enrollee’s request to disenroll, 
1049  the agency is not required to make a determination in the case. 
1050  The agency must make a determination and take final action on a 
1051  recipient’s request so that disenrollment occurs no later than 
1052  the first day of the second month after the month the request 
1053  was made. If the agency fails to act within the specified 
1054  timeframe, the recipient’s request to disenroll is deemed to be 
1055  approved as of the date agency action was required. Recipients 
1056  who disagree with the agency’s finding that cause does not exist 
1057  for disenrollment shall be advised of their right to pursue a 
1058  Medicaid fair hearing to dispute the agency’s finding. 
1059         (f) The agency shall apply for federal waivers from the 
1060  Centers for Medicare and Medicaid Services to lock eligible 
1061  Medicaid recipients into a capitated managed care network for 12 
1062  months after an open enrollment period. After 12 months of 
1063  enrollment, a recipient may select another capitated managed 
1064  care network. However, nothing shall prevent a Medicaid 
1065  recipient from changing primary care providers within the 
1066  capitated managed care network during the 12-month period. 
1067         (g) The agency shall apply for federal waivers from the 
1068  Centers for Medicare and Medicaid Services to allow recipients 
1069  to purchase health care coverage through an employer-sponsored 
1070  health insurance plan instead of through a Medicaid-certified 
1071  plan. This provision shall be known as the opt-out option. 
1072         1. A recipient who chooses the Medicaid opt-out option 
1073  shall have an opportunity for a specified period of time, as 
1074  authorized under a waiver granted by the Centers for Medicare 
1075  and Medicaid Services, to select and enroll in a Medicaid 
1076  certified plan. If the recipient remains in the employer 
1077  sponsored plan after the specified period, the recipient shall 
1078  remain in the opt-out program for at least 1 year or until the 
1079  recipient no longer has access to employer-sponsored coverage, 
1080  until the employer’s open enrollment period for a person who 
1081  opts out in order to participate in employer-sponsored coverage, 
1082  or until the person is no longer eligible for Medicaid, 
1083  whichever time period is shorter. 
1084         2. Notwithstanding any other provision of this section, 
1085  coverage, cost sharing, and any other component of employer 
1086  sponsored health insurance shall be governed by applicable state 
1087  and federal laws. 
1088         (5) This section authorizes does not authorize the agency 
1089  to seek an extension amendment and to continue operation 
1090  implement any provision of the s. 1115 of the Social Security 
1091  Act experimental, pilot, or demonstration project waiver to 
1092  reform the state Medicaid program in any part of the state other 
1093  than the two geographic areas specified in this section unless 
1094  approved by the Legislature. 
1095         (6) The agency shall develop and submit for approval 
1096  applications for waivers of applicable federal laws and 
1097  regulations as necessary to extend and expand implement the 
1098  managed care pilot project as defined in this section. The 
1099  agency shall seek public input on the waiver and post all waiver 
1100  applications under this section on its Internet website for 30 
1101  days before submitting the applications to the United States 
1102  Centers for Medicare and Medicaid Services. The 30 days shall 
1103  commence with the initial posting and must conclude 30 days 
1104  prior to approval by the United States Centers for Medicare and 
1105  Medicaid Services. All waiver applications shall be provided for 
1106  review and comment to the appropriate committees of the Senate 
1107  and House of Representatives for at least 10 working days prior 
1108  to submission. All waivers submitted to and approved by the 
1109  United States Centers for Medicare and Medicaid Services under 
1110  this section must be approved by the Legislature. Federally 
1111  approved waivers must be submitted to the President of the 
1112  Senate and the Speaker of the House of Representatives for 
1113  referral to the appropriate legislative committees. The 
1114  appropriate committees shall recommend whether to approve the 
1115  implementation of any waivers to the Legislature as a whole. The 
1116  agency shall submit a plan containing a recommended timeline for 
1117  implementation of any waivers and budgetary projections of the 
1118  effect of the pilot program under this section on the total 
1119  Medicaid budget for the 2006-2007 through 2009-2010 state fiscal 
1120  years. This implementation plan shall be submitted to the 
1121  President of the Senate and the Speaker of the House of 
1122  Representatives at the same time any waivers are submitted for 
1123  consideration by the Legislature. The agency may implement the 
1124  waiver and special terms and conditions numbered 11-W-00206/4, 
1125  as approved by the federal Centers for Medicare and Medicaid 
1126  Services. If the agency seeks approval by the Federal Government 
1127  of any modifications to these special terms and conditions, the 
1128  agency must provide written notification of its intent to modify 
1129  these terms and conditions to the President of the Senate and 
1130  the Speaker of the House of Representatives at least 15 days 
1131  before submitting the modifications to the Federal Government 
1132  for consideration. The notification must identify all 
1133  modifications being pursued and the reason the modifications are 
1134  needed. Upon receiving federal approval of any modifications to 
1135  the special terms and conditions, the agency shall provide a 
1136  report to the Legislature describing the federally approved 
1137  modifications to the special terms and conditions within 7 days 
1138  after approval by the Federal Government. 
1139         Section 3. Paragraph (m) is added to subsection (2) of 
1140  section 409.9122, Florida Statutes, to read: 
1141         409.9122 Mandatory Medicaid managed care enrollment; 
1142  programs and procedures.— 
1143         (2) 
1144         (m)1. Time allotted pursuant to this subsection to any 
1145  Medicaid recipient for the selection of, enrollment in, or 
1146  disenrollment from a managed care plan or MediPass is tolled 
1147  throughout any month in which the enrollment broker or choice 
1148  counseling provider, whichever is applicable, has adversely 
1149  affected a beneficiary’s ability to access choice counseling or 
1150  enrollment broker services by its failure to comply with the 
1151  terms and conditions of its contract or has otherwise acted or 
1152  failed to act in a manner that the agency deems likely to 
1153  jeopardize its ability to perform its assigned responsibilities 
1154  as set forth in paragraphs (c) and (d). During any month in 
1155  which time is tolled for a recipient, he or she must be afforded 
1156  uninterrupted access to benefits and services in the same 
1157  delivery system available prior to such tolling. 
1158         2. The agency shall incorporate into all pertinent 
1159  contracts that are executed or renewed on or after July 1, 2010, 
1160  provisions authorizing and requiring the agency to impose 
1161  sanctions or fines against an enrollment broker or choice 
1162  counselor if a recipient is adversely affected due to any action 
1163  or failure to act on the part of the enrollment broker or choice 
1164  counselor. 
1165         Section 4. Section 624.35, Florida Statutes, is created to 
1166  read: 
1167         624.35 Short title.—Sections 624.35-624.352 may be cited as 
1168  the “Medicaid and Public Assistance Fraud Strike Force Act.” 
1169         Section 5. Section 624.351, Florida Statutes, is created to 
1170  read: 
1171         624.351 Medicaid and Public Assistance Fraud Strike Force.— 
1172         (1) LEGISLATIVE FINDINGS.—The Legislature finds that there 
1173  is a need to develop and implement a statewide strategy to 
1174  coordinate state and local agencies, law enforcement entities, 
1175  and investigative units in order to increase the effectiveness 
1176  of programs and initiatives dealing with the prevention, 
1177  detection, and prosecution of Medicaid and public assistance 
1178  fraud. 
1179         (2) ESTABLISHMENT.—The Medicaid and Public Assistance Fraud 
1180  Strike Force is created within the department to oversee and 
1181  coordinate state and local efforts to eliminate Medicaid and 
1182  public assistance fraud and to recover state and federal funds. 
1183  The strike force shall serve in an advisory capacity and provide 
1184  recommendations and policy alternatives to the Chief Financial 
1185  Officer. 
1186         (3) MEMBERSHIP.—The strike force shall consist of the 
1187  following 11 members who may not designate anyone to serve in 
1188  their place: 
1189         (a) The Chief Financial Officer, who shall serve as chair. 
1190         (b) The Attorney General, who shall serve as vice chair. 
1191         (c) The executive director of the Department of Law 
1192  Enforcement. 
1193         (d) The Secretary of Health Care Administration. 
1194         (e) The Secretary of Children and Family Services. 
1195         (f) The State Surgeon General. 
1196         (g) Five members appointed by the Chief Financial Officer, 
1197  consisting of two sheriffs, two chiefs of police, and one state 
1198  attorney. When making these appointments, the Chief Financial 
1199  Officer shall consider representation by geography, population, 
1200  ethnicity, and other relevant factors in order to ensure that 
1201  the membership of the strike force is representative of the 
1202  state as a whole. 
1203         (4) TERMS OF MEMBERSHIP; COMPENSATION; STAFF.— 
1204         (a) The five members appointed by the Chief Financial 
1205  Officer will serve 4-year terms; however, for the purpose of 
1206  providing staggered terms, of the initial appointments, two 
1207  members will be appointed to a 2-year term, two members will be 
1208  appointed to a 3-year term, and one member will be appointed to 
1209  a 4-year term. The remaining members are standing members of the 
1210  strike force and may not serve beyond the time he or she holds 
1211  the position that was the basis for strike force membership. A 
1212  vacancy shall be filled in the same manner as the original 
1213  appointment but only for the unexpired term. 
1214         (b) The Legislature finds that the strike force serves a 
1215  legitimate state, county, and municipal purpose and that service 
1216  on the strike force is consistent with a member’s principal 
1217  service in a public office or employment. Therefore membership 
1218  on the strike force does not disqualify a member from holding 
1219  any other public office or from being employed by a public 
1220  entity, except that a member of the Legislature may not serve on 
1221  the strike force. 
1222         (c) Members of the strike force shall serve without 
1223  compensation, but are entitled to reimbursement for per diem and 
1224  travel expenses pursuant to s. 112.061. Reimbursements may be 
1225  paid from appropriations provided to the department by the 
1226  Legislature for the purposes of this section. 
1227         (d) The Chief Financial Officer shall appoint a chief of 
1228  staff for the strike force who must have experience, education, 
1229  and expertise in the fields of law, prosecution, or fraud 
1230  investigations and shall serve at the pleasure of the Chief 
1231  Financial Officer. The department shall provide the strike force 
1232  with staff necessary to assist the strike force in the 
1233  performance of its duties. 
1234         (5) MEETINGS.—The strike force shall hold its 
1235  organizational session by March 1, 2011. Thereafter, the strike 
1236  force shall meet at least four times per year. Additional 
1237  meetings may be held if the chair determines that extraordinary 
1238  circumstances require an additional meeting. Members may appear 
1239  by electronic means. A majority of the members of the strike 
1240  force constitutes a quorum. 
1241         (6) STRIKE FORCE DUTIES.—The strike force shall provide 
1242  advice and make recommendations, as necessary, to the Chief 
1243  Financial Officer. 
1244         (a) The strike force may advise the Chief Financial Officer 
1245  on initiatives that include, but are not limited to: 
1246         1. Conducting a census of local, state, and federal efforts 
1247  to address Medicaid and public assistance fraud in this state, 
1248  including fraud detection, prevention, and prosecution, in order 
1249  to discern overlapping missions, maximize existing resources, 
1250  and strengthen current programs. 
1251         2. Developing a strategic plan for coordinating and 
1252  targeting state and local resources for preventing and 
1253  prosecuting Medicaid and public assistance fraud. The plan must 
1254  identify methods to enhance multiagency efforts that contribute 
1255  to achieving the state’s goal of eliminating Medicaid and public 
1256  assistance fraud. 
1257         3. Identifying methods to implement innovative technology 
1258  and data sharing in order to detect and analyze Medicaid and 
1259  public assistance fraud with speed and efficiency. 
1260         4. Establishing a program to provide grants to state and 
1261  local agencies that develop and implement effective Medicaid and 
1262  public assistance fraud prevention, detection, and investigation 
1263  programs, which are evaluated by the strike force and ranked by 
1264  their potential to contribute to achieving the state’s goal of 
1265  eliminating Medicaid and public assistance fraud. The grant 
1266  program may also provide startup funding for new initiatives by 
1267  local and state law enforcement or administrative agencies to 
1268  combat Medicaid and public assistance fraud. 
1269         5. Developing and promoting crime prevention services and 
1270  educational programs that serve the public, including, but not 
1271  limited to, a well-publicized rewards program for the 
1272  apprehension and conviction of criminals who perpetrate Medicaid 
1273  and public assistance fraud. 
1274         6. Providing grants, contingent upon appropriation, for 
1275  multiagency or state and local Medicaid and public assistance 
1276  fraud efforts, which include, but are not limited to: 
1277         a. Providing for a Medicaid and public assistance fraud 
1278  prosecutor in the Office of the Statewide Prosecutor. 
1279         b. Providing assistance to state attorneys for support 
1280  services or equipment, or for the hiring of assistant state 
1281  attorneys, as needed, to prosecute Medicaid and public 
1282  assistance fraud cases. 
1283         c. Providing assistance to judges for support services or 
1284  for the hiring of senior judges, as needed, so that Medicaid and 
1285  public assistance fraud cases can be heard expeditiously. 
1286         (b) The strike force shall receive periodic reports from 
1287  state agencies, law enforcement officers, investigators, 
1288  prosecutors, and coordinating teams regarding Medicaid and 
1289  public assistance criminal and civil investigations. Such 
1290  reports may include discussions regarding significant factors 
1291  and trends relevant to a statewide Medicaid and public 
1292  assistance fraud strategy. 
1293         (7) REPORTS.—The strike force shall annually prepare and 
1294  submit a report on its activities and recommendations, by 
1295  October 1, to the President of the Senate, the Speaker of the 
1296  House of Representatives, the Governor, and the chairs of the 
1297  House of Representatives and Senate committees that have 
1298  substantive jurisdiction over Medicaid and public assistance 
1299  fraud. 
1300         Section 6. Section 624.352, Florida Statutes, is created to 
1301  read: 
1302         624.352 Interagency agreements to detect and deter Medicaid 
1303  and public assistance fraud.— 
1304         (1) The Chief Financial Officer shall prepare model 
1305  interagency agreements for the coordination of prevention, 
1306  investigation, and prosecution of Medicaid and public assistance 
1307  fraud to be known as “Strike Force” agreements. Parties to such 
1308  agreements may include any agency that is headed by a Cabinet 
1309  officer, the Governor, the Governor and Cabinet, a collegial 
1310  body, or any federal, state, or local law enforcement agency. 
1311         (2) The agreements must include, but are not limited to: 
1312         (a) Establishing the agreement’s purpose, mission, 
1313  authority, organizational structure, procedures, supervision, 
1314  operations, deputations, funding, expenditures, property and 
1315  equipment, reports and records, assets and forfeitures, media 
1316  policy, liability, and duration. 
1317         (b) Requiring that parties to an agreement have appropriate 
1318  powers and authority relative to the purpose and mission of the 
1319  agreement. 
1320         Section 7. Section 16.59, Florida Statutes, is amended to 
1321  read: 
1322         16.59 Medicaid fraud control.—The Medicaid Fraud Control 
1323  Unit There is created in the Department of Legal Affairs to the 
1324  Medicaid Fraud Control Unit, which may investigate all 
1325  violations of s. 409.920 and any criminal violations discovered 
1326  during the course of those investigations. The Medicaid Fraud 
1327  Control Unit may refer any criminal violation so uncovered to 
1328  the appropriate prosecuting authority. The offices of the 
1329  Medicaid Fraud Control Unit, and the offices of the Agency for 
1330  Health Care Administration Medicaid program integrity program, 
1331  and the Divisions of Insurance Fraud and Public Assistance Fraud 
1332  within the Department of Financial Services shall, to the extent 
1333  possible, be collocated; however, positions dedicated to 
1334  Medicaid managed care fraud within the Medicaid Fraud Control 
1335  Unit shall be collocated with the Division of Insurance Fraud. 
1336  The Agency for Health Care Administration, and the Department of 
1337  Legal Affairs, and the Divisions of Insurance Fraud and Public 
1338  Assistance Fraud within the Department of Financial Services 
1339  shall conduct joint training and other joint activities designed 
1340  to increase communication and coordination in recovering 
1341  overpayments. 
1342         Section 8. Paragraph (o) is added to subsection (2) of 
1343  section 20.121, Florida Statutes, to read: 
1344         20.121 Department of Financial Services.—There is created a 
1345  Department of Financial Services. 
1346         (2) DIVISIONS.—The Department of Financial Services shall 
1347  consist of the following divisions: 
1348         (o) The Division of Public Assistance Fraud. 
1349         Section 9. Paragraph (b) of subsection (7) of section 
1350  411.01, Florida Statutes, is amended to read: 
1351         411.01 School readiness programs; early learning 
1352  coalitions.— 
1353         (7) PARENTAL CHOICE.— 
1354         (b) If it is determined that a provider has provided any 
1355  cash to the beneficiary in return for receiving the purchase 
1356  order, the early learning coalition or its fiscal agent shall 
1357  refer the matter to the Department of Financial Services 
1358  pursuant to s. 414.411 Division of Public Assistance Fraud for 
1359  investigation. 
1360         Section 10. Subsection (2) of section 414.33, Florida 
1361  Statutes, is amended to read: 
1362         414.33 Violations of food stamp program.— 
1363         (2) In addition, the department shall establish procedures 
1364  for referring to the Department of Law Enforcement any case that 
1365  involves a suspected violation of federal or state law or rules 
1366  governing the administration of the food stamp program to the 
1367  Department of Financial Services pursuant to s. 414.411. 
1368         Section 11. Subsection (9) of section 414.39, Florida 
1369  Statutes, is amended to read: 
1370         414.39 Fraud.— 
1371         (9) All records relating to investigations of public 
1372  assistance fraud in the custody of the department and the Agency 
1373  for Health Care Administration are available for examination by 
1374  the Department of Financial Services Law Enforcement pursuant to 
1375  s. 414.411 943.401 and are admissible into evidence in 
1376  proceedings brought under this section as business records 
1377  within the meaning of s. 90.803(6). 
1378         Section 12. Section 943.401, Florida Statutes, is 
1379  transferred, renumbered as section 414.411, Florida Statutes, 
1380  and amended to read: 
1381         414.411 943.401 Public assistance fraud.— 
1382         (1)(a) The Department of Financial Services Law Enforcement 
1383  shall investigate all public assistance provided to residents of 
1384  the state or provided to others by the state. In the course of 
1385  such investigation the department of Law Enforcement shall 
1386  examine all records, including electronic benefits transfer 
1387  records and make inquiry of all persons who may have knowledge 
1388  as to any irregularity incidental to the disbursement of public 
1389  moneys, food stamps, or other items or benefits authorizations 
1390  to recipients. 
1391         (b) All public assistance recipients, as a condition 
1392  precedent to qualification for public assistance received and as 
1393  defined under the provisions of chapter 409, chapter 411, or 
1394  this chapter 414, must shall first give in writing, to the 
1395  Agency for Health Care Administration, the Department of Health, 
1396  the Agency for Workforce Innovation, and the Department of 
1397  Children and Family Services, as appropriate, and to the 
1398  Department of Financial Services Law Enforcement, consent to 
1399  make inquiry of past or present employers and records, financial 
1400  or otherwise. 
1401         (2) In the conduct of such investigation the Department of 
1402  Financial Services Law Enforcement may employ persons having 
1403  such qualifications as are useful in the performance of this 
1404  duty. 
1405         (3) The results of such investigation shall be reported by 
1406  the Department of Financial Services Law Enforcement to the 
1407  appropriate legislative committees, the Agency for Health Care 
1408  Administration, the Department of Health, the Agency for 
1409  Workforce Innovation, and the Department of Children and Family 
1410  Services, and to such others as the department of Law 
1411  Enforcement may determine. 
1412         (4) The Department of Health and the Department of Children 
1413  and Family Services shall report to the Department of Financial 
1414  Services Law Enforcement the final disposition of all cases 
1415  wherein action has been taken pursuant to s. 414.39, based upon 
1416  information furnished by the Department of Financial Services 
1417  Law Enforcement. 
1418         (5) All lawful fees and expenses of officers and witnesses, 
1419  expenses incident to taking testimony and transcripts of 
1420  testimony and proceedings are a proper charge to the Department 
1421  of Financial Services Law Enforcement. 
1422         (6) The provisions of this section shall be liberally 
1423  construed in order to carry out effectively the purposes of this 
1424  section in the interest of protecting public moneys and other 
1425  public property. 
1426         Section 13. Review of the Medicaid fraud and abuse 
1427  processes.— 
1428         (1) The Auditor General and the Office of Program Policy 
1429  Analysis and Government Accountability shall review and evaluate 
1430  the Agency for Health Care Administration’s Medicaid fraud and 
1431  abuse systems, including the Medicaid program integrity program. 
1432  The reviewers may access Medicaid-related information and data 
1433  from the Attorney General’s Medicaid Fraud Control Unit, the 
1434  Department of Health, the Department of Elderly Affairs, the 
1435  Agency for Persons with Disabilities, and the Department of 
1436  Children and Family Services, as necessary, to conduct the 
1437  review. The review must include, but is not limited to: 
1438         (a) An evaluation of current Medicaid policies and the 
1439  Medicaid fiscal agent; 
1440         (b) An analysis of the Medicaid fraud and abuse prevention 
1441  and detection processes, including agency contracts, Medicaid 
1442  databases, and internal control risk assessments; 
1443         (c) A comprehensive evaluation of the effectiveness of the 
1444  current laws, rules, and contractual requirements that govern 
1445  Medicaid managed care entities; 
1446         (d) An evaluation of the agency’s Medicaid managed care 
1447  oversight processes; 
1448         (e) Recommendations to improve the Medicaid claims 
1449  adjudication process, to increase the overall efficiency of the 
1450  Medicaid program, and to reduce Medicaid overpayments; and 
1451         (f) Operational and legislative recommendations to improve 
1452  the prevention and detection of fraud and abuse in the Medicaid 
1453  managed care program. 
1454         (2) The Auditor General’s Office and the Office of Program 
1455  Policy Analysis and Government Accountability may contract with 
1456  technical consultants to assist in the performance of the 
1457  review. The Auditor General and the Office of Program Policy 
1458  Analysis and Government Accountability shall report to the 
1459  President of the Senate, the Speaker of the House of 
1460  Representatives, and the Governor by December 1, 2011. 
1461         Section 14. Medicaid claims adjudication project.—The 
1462  Agency for Health Care Administration shall issue a competitive 
1463  procurement pursuant to chapter 287, Florida Statutes, with a 
1464  third-party vendor, at no cost to the state, to provide a real 
1465  time, front-end database to augment the Medicaid fiscal agent 
1466  program edits and claims adjudication process. The vendor shall 
1467  provide an interface with the Medicaid fiscal agent to decrease 
1468  inaccurate payment to Medicaid providers and improve the overall 
1469  efficiency of the Medicaid claims-processing system. 
1470         Section 15. All powers, duties, functions, records, 
1471  offices, personnel, property, pending issues and existing 
1472  contracts, administrative authority, administrative rules, and 
1473  unexpended balances of appropriations, allocations, and other 
1474  funds relating to public assistance fraud in the Department of 
1475  Law Enforcement are transferred by a type two transfer, as 
1476  defined in s. 20.06(2), Florida Statutes, to the Division of 
1477  Public Assistance Fraud in the Department of Financial Services. 
1478         Section 16. Except for sections 1, 2, 3, and 13 of this act 
1479  and this section, which shall take effect July 1, 2010, sections 
1480  4, 5, 6, 7, 8, 9, 10, 11, 12, 14, and 15 shall take effect 
1481  January 1, 2011.