Bill Text: FL S2508 | 2016 | Regular Session | Introduced


Bill Title: Health Care Services

Spectrum: Committee Bill

Status: (Introduced - Dead) 2016-02-11 - Laid on Table, companion bill(s) passed, see HB 5001 (Ch. 2016-66), HB 5003 (Ch. 2016-62), HB 5101 (Ch. 2016-65) [S2508 Detail]

Download: Florida-2016-S2508-Introduced.html
       Florida Senate - 2016                                    SB 2508
       
       
        
       By the Committee on Appropriations
       
       576-02995-16                                          20162508__
    1                        A bill to be entitled                      
    2         An act relating to health care services; amending s.
    3         322.143, F.S.; providing an exception to the
    4         prohibition against a private entity swiping an
    5         individual’s driver license or identification card for
    6         certain entities for certain purposes; amending s.
    7         395.602, F.S.; including specified hospitals in the
    8         definition of “rural hospital”; amending s. 409.285,
    9         F.S.; requiring appeals related to Medicaid programs
   10         directly administered by the Agency for Health Care
   11         Administration to be directed to the agency; providing
   12         requirements for appeals directed to the agency;
   13         providing an exemption from the uniform rules of
   14         procedure and from a requirement that certain
   15         proceedings be heard before an administrative law
   16         judge for specified hearings; requiring the agency to
   17         seek federal approval of its authority to oversee
   18         appeals; providing that appeals related to Medicaid
   19         programs administered by the Agency for Persons with
   20         Disabilities are subject to that agency’s hearing
   21         rights process; amending s. 409.811, F.S.; defining
   22         the term “lawfully residing child”; deleting the
   23         definition of the term “qualified alien”; conforming
   24         provisions to changes made by the act; amending s.
   25         409.814, F.S.; revising eligibility for the Florida
   26         Kidcare program to conform to changes made by the act;
   27         clarifying that undocumented immigrants are excluded
   28         from eligibility; amending s. 409.904, F.S.; providing
   29         eligibility for optional payments for medical
   30         assistance and related services for certain lawfully
   31         residing children; clarifying that undocumented
   32         immigrants are excluded from eligibility for optional
   33         Medicaid payments or related services; amending s.
   34         409.905, F.S.; deleting the limitation on the number
   35         of hospital emergency department visits that may be
   36         paid for by the Agency for Health Care Administration
   37         for certain recipients; amending s. 409.906, F.S.;
   38         directing the agency to seek federal approval to
   39         provide temporary housing assistance for certain
   40         persons; creating s. 409.9064, F.S.; directing the
   41         agency to seek federal approval to provide home and
   42         community-based services for individuals diagnosed
   43         with Phelan-McDermid Syndrome; providing a method for
   44         determining financial eligibility for Medicaid
   45         benefits in certain circumstances; amending s.
   46         409.907, F.S.; authorizing the agency to certify that
   47         a Medicaid provider is out of business; creating s.
   48         409.9072, F.S.; directing the agency to pay private
   49         schools and charter schools that are Medicaid
   50         providers for specified school-based services under
   51         certain parameters; authorizing the agency to review a
   52         school that has applied to the program for capability
   53         requirements; providing a reimbursement schedule;
   54         providing for a waiver of agency and school
   55         confidentiality under certain circumstances; amending
   56         s. 409.908, F.S.; revising the list of provider types
   57         that are subject to certain statutory provisions
   58         relating to the establishment of rates; amending s.
   59         409.909; adding psychiatry to a list of primary care
   60         specialties under the Statewide Medicaid Residency
   61         Program; amending s. 409.911, F.S.; updating the
   62         fiscal year for determining each hospital’s Medicaid
   63         days and charity care; providing an exception for the
   64         distribution of moneys to certain hospitals for the
   65         2016-2017 state fiscal year; amending ss. 409.9113,
   66         409.9115, and 409.9119, F.S.; providing an exception
   67         for the distribution of moneys to certain hospitals
   68         for the 2016-2017 state fiscal year; amending s.
   69         409.9128, F.S.; conforming provisions to changes made
   70         by the act; amending s. 409.967, F.S.; defining the
   71         term “Medicaid rate” for the purpose of determining
   72         specified managed care plan payments for emergency
   73         services in compliance with federal law; requiring
   74         annual publication of fee schedules on the agency’s
   75         website; amending s. 409.968, F.S.; directing the
   76         agency to establish a payment methodology for managed
   77         care plans providing housing assistance to specified
   78         persons; amending s. 409.975, F.S.; providing for the
   79         determination of applicable Medicaid rates for
   80         emergency services; defining the term “essential
   81         provider”; deleting requirements relating to
   82         contracted rates between managed care plans and
   83         hospitals; conforming provisions to changes made by
   84         the act; amending s. 624.91, F.S.; conforming
   85         provisions to changes made by the act; amending s.
   86         641.513, F.S.; specifying parameters for payments by a
   87         health maintenance organization to a noncontracted
   88         provider of emergency services under certain
   89         circumstances; conforming provisions to changes made
   90         by the act; authorizing a Program of All-Inclusive
   91         Care for the Elderly organization granted certain
   92         enrollee slots for frail elders residing in Broward
   93         County to also use the slots for enrollees residing in
   94         Miami-Dade County; authorizing the agency to contract
   95         with an organization in Escambia County to provide
   96         services under the federal Program of All-inclusive
   97         Care for the Elderly in specified areas; exempting the
   98         organization from ch. 641, F.S., relating to health
   99         care service programs; authorizing enrollment slots
  100         for the program in such areas, subject to
  101         appropriation; providing effective dates.
  102          
  103  Be It Enacted by the Legislature of the State of Florida:
  104  
  105         Section 1. Subsection (2) of section 322.143, Florida
  106  Statutes, is amended and subsection (10) is added to that
  107  section, to read:
  108         322.143 Use of a driver license or identification card.—
  109         (2) Except as provided in subsections (6) and (10)
  110  subsection (6), a private entity may not swipe an individual’s
  111  driver license or identification card, except for the following
  112  purposes:
  113         (a) To verify the authenticity of a driver license or
  114  identification card or to verify the identity of the individual
  115  if the individual pays for a good or service with a method other
  116  than cash, returns an item, or requests a refund.
  117         (b) To verify the individual’s age when providing an age
  118  restricted good or service.
  119         (c) To prevent fraud or other criminal activity if an
  120  individual returns an item or requests a refund and the private
  121  entity uses a fraud prevention service company or system.
  122         (d) To transmit information to a check services company for
  123  the purpose of approving negotiable instruments, electronic
  124  funds transfers, or similar methods of payment.
  125         (e) To comply with a legal requirement to record, retain,
  126  or transmit the driver license information.
  127         (10) To combat health care fraud, the Department of Highway
  128  Safety and Motor Vehicles shall provide photographic access,
  129  pursuant to a written agreement, with hospitals, insurance
  130  companies, or their software providers, for the purpose of
  131  verifying a patient’s identity or Medicaid eligibility by
  132  swiping an individual’s driver license or identification card.
  133         Section 2. Paragraph (e) of subsection (2) of section
  134  395.602, Florida Statutes, is amended to read:
  135         395.602 Rural hospitals.—
  136         (2) DEFINITIONS.—As used in this part, the term:
  137         (e) “Rural hospital” means an acute care hospital licensed
  138  under this chapter, having 100 or fewer licensed beds and an
  139  emergency room, which is:
  140         1. The sole provider within a county with a population
  141  density of up to 100 persons per square mile;
  142         2. An acute care hospital, in a county with a population
  143  density of up to 100 persons per square mile, which is at least
  144  30 minutes of travel time, on normally traveled roads under
  145  normal traffic conditions, from any other acute care hospital
  146  within the same county;
  147         3. A hospital supported by a tax district or subdistrict
  148  whose boundaries encompass a population of up to 100 persons per
  149  square mile;
  150         4. A hospital classified as a sole community hospital under
  151  42 C.F.R. s. 412.92 which has up to 175 licensed beds.
  152         5.4. A hospital with a service area that has a population
  153  of up to 100 persons per square mile. As used in this
  154  subparagraph, the term “service area” means the fewest number of
  155  zip codes that account for 75 percent of the hospital’s
  156  discharges for the most recent 5-year period, based on
  157  information available from the hospital inpatient discharge
  158  database in the Florida Center for Health Information and Policy
  159  Analysis at the agency; or
  160         6.5. A hospital designated as a critical access hospital,
  161  as defined in s. 408.07.
  162  
  163  Population densities used in this paragraph must be based upon
  164  the most recently completed United States census. A hospital
  165  that received funds under s. 409.9116 for a quarter beginning no
  166  later than July 1, 2002, is deemed to have been and shall
  167  continue to be a rural hospital from that date through June 30,
  168  2021, if the hospital continues to have up to 100 licensed beds
  169  and an emergency room. An acute care hospital that has not
  170  previously been designated as a rural hospital and that meets
  171  the criteria of this paragraph shall be granted such designation
  172  upon application, including supporting documentation, to the
  173  agency. A hospital that was licensed as a rural hospital during
  174  the 2010-2011 or 2011-2012 fiscal year shall continue to be a
  175  rural hospital from the date of designation through June 30,
  176  2021, if the hospital continues to have up to 100 licensed beds
  177  and an emergency room.
  178         Section 3. Section 409.285, Florida Statutes, is amended to
  179  read:
  180         409.285 Opportunity for hearing and appeal.—
  181         (1) If an application for public assistance is not acted
  182  upon within a reasonable time after the filing of the
  183  application, or is denied in whole or in part, or if an
  184  assistance payment is modified or canceled, the applicant or
  185  recipient may appeal the decision to the Department of Children
  186  and Families in the manner and form prescribed by the
  187  department.
  188         (a)(2) The hearing authority may be the Secretary of
  189  Children and Families, a panel of department officials, or a
  190  hearing officer appointed for that purpose. The hearing
  191  authority is responsible for a final administrative decision in
  192  the name of the department on all issues that have been the
  193  subject of a hearing. With regard to the department, the
  194  decision of the hearing authority is final and binding. The
  195  department is responsible for seeing that the decision is
  196  carried out promptly.
  197         (b)(3) The department may adopt rules to administer this
  198  subsection section. Rules for the Temporary Assistance for Needy
  199  Families block grant programs must be similar to the federal
  200  requirements for Medicaid programs.
  201         (2) Appeals related to Medicaid programs directly
  202  administered by the Agency for Health Care Administration,
  203  including appeals related to Florida’s Statewide Medicaid
  204  Managed Care program and associated federal waivers, must be
  205  directed to the Agency for Health Care Administration in the
  206  manner and form prescribed by the agency.
  207         (a) The hearing authority for appeals heard by the Agency
  208  for Health Care Administration may be the secretary of the
  209  agency, a panel of agency officials, or a hearing officer
  210  appointed for that purpose. The hearing authority is responsible
  211  for a final administrative decision in the name of the agency on
  212  all issues that have been the subject of a hearing. A decision
  213  of the hearing authority is final and binding on the agency. The
  214  agency is responsible for seeing that the decision is promptly
  215  carried out.
  216         (b) Notwithstanding ss. 120.569 and 120.57, hearings
  217  conducted by the Agency for Health Care Administration pursuant
  218  to this subsection are exempt from the uniform rules of
  219  procedure under s. 120.54(5) and do not need to be conducted by
  220  an administrative law judge assigned by the Division of
  221  Administrative Hearings.
  222         (c) The Agency for Health Care Administration shall seek
  223  federal approval necessary to implement this subsection and may
  224  adopt rules necessary to administer this subsection.
  225         (3) Appeals related to Medicaid programs administered by
  226  the Agency for Persons with Disabilities are subject to s.
  227  393.125.
  228         Section 4. Present subsections (17) through (22) of section
  229  409.811, Florida Statutes, are redesignated as subsections (18)
  230  through (23), respectively, a new subsection (17) is added to
  231  that section, and present subsections (23) and (24) of that
  232  section are amended, to read:
  233         409.811 Definitions relating to Florida Kidcare Act.—As
  234  used in ss. 409.810-409.821, the term:
  235         (17) “Lawfully residing child” means a child who is
  236  lawfully present in the United States, meets Medicaid or
  237  Children’s Health Insurance Program (CHIP) residency
  238  requirements, and may be eligible for medical assistance with
  239  federal financial participation as provided under s. 214 of the
  240  Children’s Health Insurance Program Reauthorization Act of 2009,
  241  Pub. L. No. 111-3, and related federal regulations.
  242         (23) “Qualified alien” means an alien as defined in s. 431
  243  of the Personal Responsibility and Work Opportunity
  244  Reconciliation Act of 1996, as amended, Pub. L. No. 104-193.
  245         (24) “Resident” means a United States citizen, or lawfully
  246  residing child qualified alien, who is domiciled in this state.
  247         Section 5. Paragraph (c) of subsection (4) of section
  248  409.814, Florida Statutes, is amended to read:
  249         409.814 Eligibility.—A child who has not reached 19 years
  250  of age whose family income is equal to or below 200 percent of
  251  the federal poverty level is eligible for the Florida Kidcare
  252  program as provided in this section. If an enrolled individual
  253  is determined to be ineligible for coverage, he or she must be
  254  immediately disenrolled from the respective Florida Kidcare
  255  program component.
  256         (4) The following children are not eligible to receive
  257  Title XXI-funded premium assistance for health benefits coverage
  258  under the Florida Kidcare program, except under Medicaid if the
  259  child would have been eligible for Medicaid under s. 409.903 or
  260  s. 409.904 as of June 1, 1997:
  261         (c) A child who is an alien, but who does not meet the
  262  definition of a lawfully residing child qualified alien, in the
  263  United States. This paragraph does not extend eligibility for
  264  the Florida Kidcare program to an undocumented immigrant.
  265         Section 6. Present subsections (8) and (9) of section
  266  409.904, Florida Statutes, are redesignated as subsections (9)
  267  and (10), respectively, and a new subsection (8) is added to
  268  that section, to read:
  269         409.904 Optional payments for eligible persons.—The agency
  270  may make payments for medical assistance and related services on
  271  behalf of the following persons who are determined to be
  272  eligible subject to the income, assets, and categorical
  273  eligibility tests set forth in federal and state law. Payment on
  274  behalf of these Medicaid eligible persons is subject to the
  275  availability of moneys and any limitations established by the
  276  General Appropriations Act or chapter 216.
  277         (8) A child who has not attained 19 years of age and who,
  278  notwithstanding s. 414.095(3), would be eligible for Medicaid
  279  under s. 409.903, except that the child is a lawfully residing
  280  child as defined in s. 409.811. This subsection does not extend
  281  eligibility for optional Medicaid payments or related services
  282  to an undocumented immigrant.
  283         Section 7. Subsection (5) of section 409.905, Florida
  284  Statutes, is amended to read:
  285         409.905 Mandatory Medicaid services.—The agency may make
  286  payments for the following services, which are required of the
  287  state by Title XIX of the Social Security Act, furnished by
  288  Medicaid providers to recipients who are determined to be
  289  eligible on the dates on which the services were provided. Any
  290  service under this section shall be provided only when medically
  291  necessary and in accordance with state and federal law.
  292  Mandatory services rendered by providers in mobile units to
  293  Medicaid recipients may be restricted by the agency. Nothing in
  294  this section shall be construed to prevent or limit the agency
  295  from adjusting fees, reimbursement rates, lengths of stay,
  296  number of visits, number of services, or any other adjustments
  297  necessary to comply with the availability of moneys and any
  298  limitations or directions provided for in the General
  299  Appropriations Act or chapter 216.
  300         (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for
  301  all covered services provided for the medical care and treatment
  302  of a recipient who is admitted as an inpatient by a licensed
  303  physician or dentist to a hospital licensed under part I of
  304  chapter 395. However, the agency shall limit the payment for
  305  inpatient hospital services for a Medicaid recipient 21 years of
  306  age or older to 45 days or the number of days necessary to
  307  comply with the General Appropriations Act. Effective August 1,
  308  2012, the agency shall limit payment for hospital emergency
  309  department visits for a nonpregnant Medicaid recipient 21 years
  310  of age or older to six visits per fiscal year.
  311         (a) The agency may implement reimbursement and utilization
  312  management reforms in order to comply with any limitations or
  313  directions in the General Appropriations Act, which may include,
  314  but are not limited to: prior authorization for inpatient
  315  psychiatric days; prior authorization for nonemergency hospital
  316  inpatient admissions for individuals 21 years of age and older;
  317  authorization of emergency and urgent-care admissions within 24
  318  hours after admission; enhanced utilization and concurrent
  319  review programs for highly utilized services; reduction or
  320  elimination of covered days of service; adjusting reimbursement
  321  ceilings for variable costs; adjusting reimbursement ceilings
  322  for fixed and property costs; and implementing target rates of
  323  increase. The agency may limit prior authorization for hospital
  324  inpatient services to selected diagnosis-related groups, based
  325  on an analysis of the cost and potential for unnecessary
  326  hospitalizations represented by certain diagnoses. Admissions
  327  for normal delivery and newborns are exempt from requirements
  328  for prior authorization. In implementing the provisions of this
  329  section related to prior authorization, the agency shall ensure
  330  that the process for authorization is accessible 24 hours per
  331  day, 7 days per week and authorization is automatically granted
  332  when not denied within 4 hours after the request. Authorization
  333  procedures must include steps for review of denials. Upon
  334  implementing the prior authorization program for hospital
  335  inpatient services, the agency shall discontinue its hospital
  336  retrospective review program.
  337         (b) A licensed hospital maintained primarily for the care
  338  and treatment of patients having mental disorders or mental
  339  diseases is not eligible to participate in the hospital
  340  inpatient portion of the Medicaid program except as provided in
  341  federal law. However, the department shall apply for a waiver,
  342  within 9 months after June 5, 1991, designed to provide
  343  hospitalization services for mental health reasons to children
  344  and adults in the most cost-effective and lowest cost setting
  345  possible. Such waiver shall include a request for the
  346  opportunity to pay for care in hospitals known under federal law
  347  as “institutions for mental disease” or “IMD’s.” The waiver
  348  proposal shall propose no additional aggregate cost to the state
  349  or Federal Government, and shall be conducted in Hillsborough
  350  County, Highlands County, Hardee County, Manatee County, and
  351  Polk County. The waiver proposal may incorporate competitive
  352  bidding for hospital services, comprehensive brokering, prepaid
  353  capitated arrangements, or other mechanisms deemed by the
  354  department to show promise in reducing the cost of acute care
  355  and increasing the effectiveness of preventive care. When
  356  developing the waiver proposal, the department shall take into
  357  account price, quality, accessibility, linkages of the hospital
  358  to community services and family support programs, plans of the
  359  hospital to ensure the earliest discharge possible, and the
  360  comprehensiveness of the mental health and other health care
  361  services offered by participating providers.
  362         (c) The agency shall implement a prospective payment
  363  methodology for establishing reimbursement rates for inpatient
  364  hospital services. Rates shall be calculated annually and take
  365  effect July 1 of each year. The methodology shall categorize
  366  each inpatient admission into a diagnosis-related group and
  367  assign a relative payment weight to the base rate according to
  368  the average relative amount of hospital resources used to treat
  369  a patient in a specific diagnosis-related group category. The
  370  agency may adopt the most recent relative weights calculated and
  371  made available by the Nationwide Inpatient Sample maintained by
  372  the Agency for Healthcare Research and Quality or may adopt
  373  alternative weights if the agency finds that Florida-specific
  374  weights deviate with statistical significance from national
  375  weights for high-volume diagnosis-related groups. The agency
  376  shall establish a single, uniform base rate for all hospitals
  377  unless specifically exempt pursuant to s. 409.908(1).
  378         1. Adjustments may not be made to the rates after October
  379  31 of the state fiscal year in which the rates take effect,
  380  except for cases of insufficient collections of
  381  intergovernmental transfers authorized under s. 409.908(1) or
  382  the General Appropriations Act. In such cases, the agency shall
  383  submit a budget amendment or amendments under chapter 216
  384  requesting approval of rate reductions by amounts necessary for
  385  the aggregate reduction to equal the dollar amount of
  386  intergovernmental transfers not collected and the corresponding
  387  federal match. Notwithstanding the $1 million limitation on
  388  increases to an approved operating budget contained in ss.
  389  216.181(11) and 216.292(3), a budget amendment exceeding that
  390  dollar amount is subject to notice and objection procedures set
  391  forth in s. 216.177.
  392         2. Errors in source data or calculations discovered after
  393  October 31 must be reconciled in a subsequent rate period.
  394  However, the agency may not make any adjustment to a hospital’s
  395  reimbursement more than 5 years after a hospital is notified of
  396  an audited rate established by the agency. The prohibition
  397  against adjustments more than 5 years after notification is
  398  remedial and applies to actions by providers involving Medicaid
  399  claims for hospital services. Hospital reimbursement is subject
  400  to such limits or ceilings as may be established in law or
  401  described in the agency’s hospital reimbursement plan. Specific
  402  exemptions to the limits or ceilings may be provided in the
  403  General Appropriations Act.
  404         (d) The agency shall implement a comprehensive utilization
  405  management program for hospital neonatal intensive care stays in
  406  certain high-volume participating hospitals, select counties, or
  407  statewide, and replace existing hospital inpatient utilization
  408  management programs for neonatal intensive care admissions. The
  409  program shall be designed to manage appropriate admissions and
  410  discharges for children being treated in neonatal intensive care
  411  units and must seek medically appropriate discharge to the
  412  child’s home or other less costly treatment setting. The agency
  413  may competitively bid a contract for the selection of a
  414  qualified organization to provide neonatal intensive care
  415  utilization management services. The agency may seek federal
  416  waivers to implement this initiative.
  417         (e) The agency may develop and implement a program to
  418  reduce the number of hospital readmissions among the non
  419  Medicare population eligible in areas 9, 10, and 11.
  420         Section 8. Paragraph (e) is added to subsection (13) of
  421  section 409.906, Florida Statutes, to read:
  422         409.906 Optional Medicaid services.—Subject to specific
  423  appropriations, the agency may make payments for services which
  424  are optional to the state under Title XIX of the Social Security
  425  Act and are furnished by Medicaid providers to recipients who
  426  are determined to be eligible on the dates on which the services
  427  were provided. Any optional service that is provided shall be
  428  provided only when medically necessary and in accordance with
  429  state and federal law. Optional services rendered by providers
  430  in mobile units to Medicaid recipients may be restricted or
  431  prohibited by the agency. Nothing in this section shall be
  432  construed to prevent or limit the agency from adjusting fees,
  433  reimbursement rates, lengths of stay, number of visits, or
  434  number of services, or making any other adjustments necessary to
  435  comply with the availability of moneys and any limitations or
  436  directions provided for in the General Appropriations Act or
  437  chapter 216. If necessary to safeguard the state’s systems of
  438  providing services to elderly and disabled persons and subject
  439  to the notice and review provisions of s. 216.177, the Governor
  440  may direct the Agency for Health Care Administration to amend
  441  the Medicaid state plan to delete the optional Medicaid service
  442  known as “Intermediate Care Facilities for the Developmentally
  443  Disabled.” Optional services may include:
  444         (13) HOME AND COMMUNITY-BASED SERVICES.—
  445         (e) The agency shall seek federal approval to pay for
  446  flexible services for persons with severe mental illness or
  447  substance abuse disorders, including, but not limited to,
  448  temporary housing assistance. Payments may be made as enhanced
  449  capitation rates or incentive payments to managed care plans
  450  that meet the requirements of s. 409.968(4).
  451         Section 9. Section 409.9064, Florida Statutes, is created
  452  to read:
  453         409.9064 Medicaid Services for Individuals with Phelan
  454  McDermid Syndrome.—The agency shall seek federal approval of a
  455  Section 1915(i) state plan option for home and community-based
  456  services for individuals diagnosed with Phelan-McDermid
  457  Syndrome. Financial eligibility for Medicaid benefits under this
  458  plan option will be determined in the same manner as the home
  459  and community-based services waiver for persons with
  460  developmental disabilities.
  461         Section 10. Present subsection (12) of section 409.907,
  462  Florida Statutes, is redesignated as subsection (13), and a new
  463  subsection (12) is added to that subsection, to read:
  464         409.907 Medicaid provider agreements.—The agency may make
  465  payments for medical assistance and related services rendered to
  466  Medicaid recipients only to an individual or entity who has a
  467  provider agreement in effect with the agency, who is performing
  468  services or supplying goods in accordance with federal, state,
  469  and local law, and who agrees that no person shall, on the
  470  grounds of handicap, race, color, or national origin, or for any
  471  other reason, be subjected to discrimination under any program
  472  or activity for which the provider receives payment from the
  473  agency.
  474         (12) In accordance with 42 C.F.R. s. 433.318(d)(2)(ii), the
  475  agency may certify that a provider is out of business and that
  476  any overpayments made to the provider cannot be collected under
  477  state law.
  478         Section 11. Section 409.9072, Florida Statutes, is created
  479  to read:
  480         409.9072 Medicaid provider agreements for charter schools
  481  and private schools.—
  482         (1) Subject to a specific appropriation by the Legislature,
  483  the agency shall reimburse private schools as defined in s.
  484  1002.01 and schools designated as charter schools under s.
  485  1002.33 which are Medicaid providers for school-based services
  486  pursuant to the rehabilitative services option provided under 42
  487  U.S.C. s. 1396d(a)(13) to children younger than 21 years of age
  488  with specified disabilities who are eligible for both Medicaid
  489  and part B or part H of the Individuals with Disabilities
  490  Education Act (IDEA) or the exceptional student education
  491  program, or who have an individualized educational plan.
  492         (2) Schools that wish to enroll as Medicaid providers and
  493  receive Medicaid reimbursement under this section must apply to
  494  the agency for a provider agreement and must agree to:
  495         (a) Verify Medicaid eligibility. The agency shall work
  496  cooperatively with a private school or a charter school that is
  497  a Medicaid provider to facilitate the school’s verification of
  498  Medicaid eligibility.
  499         (b) Develop and maintain the financial and individual
  500  education plan records needed to document the appropriate use of
  501  state and federal Medicaid funds.
  502         (c) Comply with all state and federal Medicaid laws, rules,
  503  regulations, and policies, including, but not limited to, those
  504  related to the confidentiality of records and freedom of choice
  505  of providers.
  506         (d) Be responsible for reimbursing the cost of any state or
  507  federal disallowance that results from failure to comply with
  508  state or federal Medicaid laws, rules, or regulations.
  509         (3) The types of school-based services for which schools
  510  may be reimbursed under this section are those included in s.
  511  1011.70(1). Private schools and charter schools may not be
  512  reimbursed by the agency for providing services that are
  513  excluded by that subsection.
  514         (4) Within 90 days after a private school or a charter
  515  school applies to enroll as a Medicaid provider under this
  516  section, the agency may conduct a review to ensure that the
  517  school has the capability to comply with its responsibilities
  518  under subsection (2). A finding by the agency that the school
  519  has the capability to comply does not relieve the school of its
  520  responsibility to correct any deficiencies or to reimburse the
  521  cost of the state or federal disallowances identified pursuant
  522  to any subsequent state or federal audits.
  523         (5) For reimbursements to private schools and charter
  524  schools under this section, the agency shall apply the
  525  reimbursement schedule developed under s. 409.9071(5). Health
  526  care practitioners engaged by a school to provide services under
  527  this section must be enrolled as Medicaid providers and meet the
  528  qualifications specified under 42 C.F.R. s. 440.110, as
  529  applicable. Each school’s continued participation in providing
  530  Medicaid services under this section is contingent upon the
  531  school providing to the agency an annual accounting of how the
  532  Medicaid reimbursements are used.
  533         (6) For Medicaid provider agreements issued under this
  534  section, the agency’s and the school’s confidentiality is waived
  535  in relation to the state’s efforts to control Medicaid fraud.
  536  The agency and the school shall provide any information or
  537  documents relating to this section to the Medicaid Fraud Control
  538  Unit in the Department of Legal Affairs, upon request, pursuant
  539  to the Attorney General’s authority under s. 409.920.
  540         Section 12. Effective July 1, 2017, paragraph (c) of
  541  subsection (23) of section 409.908, Florida Statutes, is amended
  542  to read:
  543         409.908 Reimbursement of Medicaid providers.—Subject to
  544  specific appropriations, the agency shall reimburse Medicaid
  545  providers, in accordance with state and federal law, according
  546  to methodologies set forth in the rules of the agency and in
  547  policy manuals and handbooks incorporated by reference therein.
  548  These methodologies may include fee schedules, reimbursement
  549  methods based on cost reporting, negotiated fees, competitive
  550  bidding pursuant to s. 287.057, and other mechanisms the agency
  551  considers efficient and effective for purchasing services or
  552  goods on behalf of recipients. If a provider is reimbursed based
  553  on cost reporting and submits a cost report late and that cost
  554  report would have been used to set a lower reimbursement rate
  555  for a rate semester, then the provider’s rate for that semester
  556  shall be retroactively calculated using the new cost report, and
  557  full payment at the recalculated rate shall be effected
  558  retroactively. Medicare-granted extensions for filing cost
  559  reports, if applicable, shall also apply to Medicaid cost
  560  reports. Payment for Medicaid compensable services made on
  561  behalf of Medicaid eligible persons is subject to the
  562  availability of moneys and any limitations or directions
  563  provided for in the General Appropriations Act or chapter 216.
  564  Further, nothing in this section shall be construed to prevent
  565  or limit the agency from adjusting fees, reimbursement rates,
  566  lengths of stay, number of visits, or number of services, or
  567  making any other adjustments necessary to comply with the
  568  availability of moneys and any limitations or directions
  569  provided for in the General Appropriations Act, provided the
  570  adjustment is consistent with legislative intent.
  571         (23)
  572         (c) This subsection applies to the following provider
  573  types:
  574         1. Inpatient hospitals.
  575         2. Outpatient hospitals.
  576         3. Nursing homes.
  577         3.4. County health departments.
  578         4.5. Prepaid health plans.
  579         Section 13. Paragraph (a) of subsection (2) of section
  580  409.909, Florida Statutes, is amended to read:
  581         409.909 Statewide Medicaid Residency Program.—
  582         (2) On or before September 15 of each year, the agency
  583  shall calculate an allocation fraction to be used for
  584  distributing funds to participating hospitals. On or before the
  585  final business day of each quarter of a state fiscal year, the
  586  agency shall distribute to each participating hospital one
  587  fourth of that hospital’s annual allocation calculated under
  588  subsection (4). The allocation fraction for each participating
  589  hospital is based on the hospital’s number of full-time
  590  equivalent residents and the amount of its Medicaid payments. As
  591  used in this section, the term:
  592         (a) “Full-time equivalent,” or “FTE,” means a resident who
  593  is in his or her residency period, with the initial residency
  594  period defined as the minimum number of years of training
  595  required before the resident may become eligible for board
  596  certification by the American Osteopathic Association Bureau of
  597  Osteopathic Specialists or the American Board of Medical
  598  Specialties in the specialty in which he or she first began
  599  training, not to exceed 5 years. The residency specialty is
  600  defined as reported using the current residency type codes in
  601  the Intern and Resident Information System (IRIS), required by
  602  Medicare. A resident training beyond the initial residency
  603  period is counted as 0.5 FTE, unless his or her chosen specialty
  604  is in primary care, in which case the resident is counted as 1.0
  605  FTE. For the purposes of this section, primary care specialties
  606  include:
  607         1. Family medicine;
  608         2. General internal medicine;
  609         3. General pediatrics;
  610         4. Preventive medicine;
  611         5. Geriatric medicine;
  612         6. Osteopathic general practice;
  613         7. Obstetrics and gynecology;
  614         8. Emergency medicine; and
  615         9. General surgery; and
  616         10. Psychiatry.
  617         Section 14. Paragraph (a) of subsection (2) of section
  618  409.911, Florida Statutes, is amended, and subsection (10) is
  619  added to that section, to read:
  620         409.911 Disproportionate share program.—Subject to specific
  621  allocations established within the General Appropriations Act
  622  and any limitations established pursuant to chapter 216, the
  623  agency shall distribute, pursuant to this section, moneys to
  624  hospitals providing a disproportionate share of Medicaid or
  625  charity care services by making quarterly Medicaid payments as
  626  required. Notwithstanding the provisions of s. 409.915, counties
  627  are exempt from contributing toward the cost of this special
  628  reimbursement for hospitals serving a disproportionate share of
  629  low-income patients.
  630         (2) The Agency for Health Care Administration shall use the
  631  following actual audited data to determine the Medicaid days and
  632  charity care to be used in calculating the disproportionate
  633  share payment:
  634         (a) The average of the 2007, 2008, and 2009 audited
  635  disproportionate share data to determine each hospital’s
  636  Medicaid days and charity care for the 2016-2017 2015-2016 state
  637  fiscal year.
  638         (10) Notwithstanding the provisions of this section to the
  639  contrary, for the 2016-2017 state fiscal year, the agency shall
  640  distribute moneys to hospitals providing a disproportionate
  641  share of Medicaid or charity care services as provided in the
  642  2016-2017 General Appropriations Act.
  643         Section 15. Subsection (3) is added to section 409.9113,
  644  Florida Statutes, to read:
  645         409.9113 Disproportionate share program for teaching
  646  hospitals.—In addition to the payments made under s. 409.911,
  647  the agency shall make disproportionate share payments to
  648  teaching hospitals, as defined in s. 408.07, for their increased
  649  costs associated with medical education programs and for
  650  tertiary health care services provided to the indigent. This
  651  system of payments must conform to federal requirements and
  652  distribute funds in each fiscal year for which an appropriation
  653  is made by making quarterly Medicaid payments. Notwithstanding
  654  s. 409.915, counties are exempt from contributing toward the
  655  cost of this special reimbursement for hospitals serving a
  656  disproportionate share of low-income patients. The agency shall
  657  distribute the moneys provided in the General Appropriations Act
  658  to statutorily defined teaching hospitals and family practice
  659  teaching hospitals, as defined in s. 395.805, pursuant to this
  660  section. The funds provided for statutorily defined teaching
  661  hospitals shall be distributed as provided in the General
  662  Appropriations Act. The funds provided for family practice
  663  teaching hospitals shall be distributed equally among family
  664  practice teaching hospitals.
  665         (3) Notwithstanding the provisions of this section to the
  666  contrary, for the 2016-2017 state fiscal year, the agency shall
  667  make disproportionate share payments to teaching hospitals, as
  668  defined in s. 408.07, as provided in the 2016-2017 General
  669  Appropriations Act.
  670         Section 16. Subsection (3) is added to section 409.9115,
  671  Florida Statutes, to read:
  672         409.9115 Disproportionate share program for mental health
  673  hospitals.—The Agency for Health Care Administration shall
  674  design and implement a system of making mental health
  675  disproportionate share payments to hospitals that qualify for
  676  disproportionate share payments under s. 409.911. This system of
  677  payments shall conform with federal requirements and shall
  678  distribute funds in each fiscal year for which an appropriation
  679  is made by making quarterly Medicaid payments. Notwithstanding
  680  s. 409.915, counties are exempt from contributing toward the
  681  cost of this special reimbursement for patients.
  682         (3) Notwithstanding the provisions of this section to the
  683  contrary, for the 2016-2017 state fiscal year, for hospitals
  684  that qualify under subsection (2), the agency shall distribute
  685  funds for the disproportionate share program for mental health
  686  hospitals in the same manner as in the 2015-2016 state fiscal
  687  year.
  688         Section 17. Subsection (4) is added to section 409.9119,
  689  Florida Statutes, to read:
  690         409.9119 Disproportionate share program for specialty
  691  hospitals for children.—In addition to the payments made under
  692  s. 409.911, the Agency for Health Care Administration shall
  693  develop and implement a system under which disproportionate
  694  share payments are made to those hospitals that are licensed by
  695  the state as specialty hospitals for children and were licensed
  696  on January 1, 2000, as specialty hospitals for children. This
  697  system of payments must conform to federal requirements and must
  698  distribute funds in each fiscal year for which an appropriation
  699  is made by making quarterly Medicaid payments. Notwithstanding
  700  s. 409.915, counties are exempt from contributing toward the
  701  cost of this special reimbursement for hospitals that serve a
  702  disproportionate share of low-income patients. The agency may
  703  make disproportionate share payments to specialty hospitals for
  704  children as provided for in the General Appropriations Act.
  705         (4) Notwithstanding the provisions of this section to the
  706  contrary, for the 2016-2017 state fiscal year, for hospitals
  707  achieving full compliance under subsection (3), the agency shall
  708  make disproportionate share payments to specialty hospitals for
  709  children as provided in the 2016-2017 General Appropriations
  710  Act.
  711         Section 18. Subsection (5) of section 409.9128, Florida
  712  Statutes, is amended to read:
  713         409.9128 Requirements for providing emergency services and
  714  care.—
  715         (5) Reimbursement for services provided to an enrollee of a
  716  managed care plan under this section by a provider who does not
  717  have a contract with the managed care plan shall be the lesser
  718  of:
  719         (a) The provider’s charges;
  720         (b) The usual and customary provider charges for similar
  721  services in the community where the services were provided;
  722         (c) The charge mutually agreed to by the entity and the
  723  provider within 60 days after submittal of the claim; or
  724         (d) The Medicaid rate, as provided in s. 409.967(2)(b).
  725         Section 19. Paragraph (b) of subsection (2) of section
  726  409.967, Florida Statutes, is amended to read:
  727         409.967 Managed care plan accountability.—
  728         (2) The agency shall establish such contract requirements
  729  as are necessary for the operation of the statewide managed care
  730  program. In addition to any other provisions the agency may deem
  731  necessary, the contract must require:
  732         (b) Emergency services.—Managed care plans shall pay for
  733  services required by ss. 395.1041 and 401.45 and rendered by a
  734  noncontracted provider. The plans must comply with s. 641.3155.
  735  Reimbursement for services under this paragraph is the lesser
  736  of:
  737         1. The provider’s charges;
  738         2. The usual and customary provider charges for similar
  739  services in the community where the services were provided;
  740         3. The charge mutually agreed to by the entity and the
  741  provider within 60 days after submittal of the claim; or
  742         4. The Medicaid rate, which, for the purposes of this
  743  paragraph, means the amount the provider would collect from the
  744  agency on a fee-for-service basis, less any amounts for the
  745  indirect costs of medical education and the direct costs of
  746  graduate medical education that are otherwise included in the
  747  agency’s fee-for-service payment, as required under 42 U.S.C. s.
  748  1396u-2(b)(2)(D) The rate the agency would have paid on the most
  749  recent October 1st.
  750  
  751  For the purpose of establishing the amounts specified in
  752  subparagraph 4., the agency shall publish on its website
  753  annually, or more frequently as needed, the applicable fee-for
  754  service fee schedules and their effective dates, less any
  755  amounts for indirect costs of medical education and direct costs
  756  of graduate medical education that are otherwise included in the
  757  agency’s fee-for-service payments.
  758         Section 20. Present subsection (4) of section 409.968,
  759  Florida Statutes, is redesignated as subsection (5) and a new
  760  subsection (4) is added to that section, to read:
  761         409.968 Managed care plan payments.—
  762         (4)(a) Subject to a specific appropriation and federal
  763  approval under s. 409.906(13)(e), the agency shall establish a
  764  payment methodology to fund managed care plans for flexible
  765  services for persons with severe mental illness and substance
  766  abuse disorders, including, but not limited to, temporary
  767  housing assistance. A managed care plan eligible for these
  768  payments must do all of the following:
  769         1. Participate as a specialty plan for severe mental
  770  illness or substance abuse disorders or participate in counties
  771  designated by the General Appropriations Act;
  772         2. Include providers of behavioral health services pursuant
  773  to chapters 394 and 397 in the managed care plan’s provider
  774  network; and
  775         3. Document a capability to provide housing assistance
  776  through agreements with housing providers, relationships with
  777  local housing coalitions, and other appropriate arrangements.
  778         (b) After receiving payments authorized by this section for
  779  at least 1 year, a managed care plan must document the results
  780  of its efforts to maintain the target population in stable
  781  housing up to the maximum duration allowed under federal
  782  approval.
  783         Section 21. Subsections (1) and (6) of section 409.975,
  784  Florida Statutes, are amended to read:
  785         409.975 Managed care plan accountability.—In addition to
  786  the requirements of s. 409.967, plans and providers
  787  participating in the managed medical assistance program shall
  788  comply with the requirements of this section.
  789         (1) PROVIDER NETWORKS.—Managed care plans must develop and
  790  maintain provider networks that meet the medical needs of their
  791  enrollees in accordance with standards established pursuant to
  792  s. 409.967(2)(c). Except as provided in this section, managed
  793  care plans may limit the providers in their networks based on
  794  credentials, quality indicators, and price.
  795         (a) Plans must include all providers in the region that are
  796  classified by the agency as essential Medicaid providers, unless
  797  the agency approves, in writing, an alternative arrangement for
  798  securing the types of services offered by the essential
  799  providers. Providers are essential for serving Medicaid
  800  enrollees if they offer services that are not available from any
  801  other provider within a reasonable access standard, or if they
  802  provided a substantial share of the total units of a particular
  803  service used by Medicaid patients within the region during the
  804  last 3 years and the combined capacity of other service
  805  providers in the region is insufficient to meet the total needs
  806  of the Medicaid patients. The agency may not classify physicians
  807  and other practitioners as essential providers. The agency, at a
  808  minimum, shall determine which providers in the following
  809  categories are essential Medicaid providers:
  810         1. Federally qualified health centers.
  811         2. Statutory teaching hospitals as defined in s.
  812  408.07(45).
  813         3. Hospitals that are trauma centers as defined in s.
  814  395.4001(14).
  815         4. Hospitals located at least 25 miles from any other
  816  hospital with similar services.
  817  
  818  Managed care plans that have not contracted with all essential
  819  providers in the region as of the first date of recipient
  820  enrollment, or with whom an essential provider has terminated
  821  its contract, must negotiate in good faith with such essential
  822  providers for 1 year or until an agreement is reached, whichever
  823  is first. Payments for services rendered by a nonparticipating
  824  essential provider shall be made at the applicable Medicaid rate
  825  as of the first day of the contract between the agency and the
  826  plan. A rate schedule for all essential providers shall be
  827  attached to the contract between the agency and the plan. After
  828  1 year, managed care plans that are unable to contract with
  829  essential providers shall notify the agency and propose an
  830  alternative arrangement for securing the essential services for
  831  Medicaid enrollees. The arrangement must rely on contracts with
  832  other participating providers, regardless of whether those
  833  providers are located within the same region as the
  834  nonparticipating essential service provider. If the alternative
  835  arrangement is approved by the agency, payments to
  836  nonparticipating essential providers after the date of the
  837  agency’s approval shall equal 90 percent of the applicable
  838  Medicaid rate. Except for payment for emergency services, if the
  839  alternative arrangement is not approved by the agency, payment
  840  to nonparticipating essential providers shall equal 110 percent
  841  of the applicable Medicaid rate.
  842         (b) Certain providers are statewide resources and essential
  843  providers for all managed care plans in all regions. All managed
  844  care plans must include these essential providers in their
  845  networks. Statewide essential providers include:
  846         1. Faculty plans of Florida medical schools.
  847         2. Regional perinatal intensive care centers as defined in
  848  s. 383.16(2).
  849         3. Hospitals licensed as specialty children’s hospitals as
  850  defined in s. 395.002(28).
  851         4. Accredited and integrated systems serving medically
  852  complex children which comprise that are comprised of separately
  853  licensed, but commonly owned, health care providers delivering
  854  at least the following services: medical group home, in-home and
  855  outpatient nursing care and therapies, pharmacy services,
  856  durable medical equipment, and Prescribed Pediatric Extended
  857  Care.
  858  
  859  Managed care plans that have not contracted with all statewide
  860  essential providers in all regions as of the first date of
  861  recipient enrollment must continue to negotiate in good faith.
  862  Payments to physicians on the faculty of nonparticipating
  863  Florida medical schools shall be made at the applicable Medicaid
  864  rate. Payments for services rendered by regional perinatal
  865  intensive care centers shall be made at the applicable Medicaid
  866  rate as of the first day of the contract between the agency and
  867  the plan. Except for payments for emergency services, payments
  868  to nonparticipating specialty children’s hospitals shall equal
  869  the highest rate established by contract between that provider
  870  and any other Medicaid managed care plan.
  871         (c) After 12 months of active participation in a plan’s
  872  network, the plan may exclude any essential provider from the
  873  network for failure to meet quality or performance criteria. If
  874  the plan excludes an essential provider from the plan, the plan
  875  must provide written notice to all recipients who have chosen
  876  that provider for care. The notice shall be provided at least 30
  877  days before the effective date of the exclusion. For the
  878  purposes of this paragraph, the term “essential provider”
  879  includes providers determined by the agency to be essential
  880  Medicaid providers under paragraph (a) and the statewide
  881  essential providers specified in paragraph (b).
  882         (d) The applicable Medicaid rates for emergency services
  883  paid by a plan under this section to a provider with which the
  884  plan does not have an active contract, shall be determined under
  885  the requirements of s. 409.967(2)(b).
  886         (e) Each managed care plan must offer a network contract to
  887  each home medical equipment and supplies provider in the region
  888  which meets quality and fraud prevention and detection standards
  889  established by the plan and which agrees to accept the lowest
  890  price previously negotiated between the plan and another such
  891  provider.
  892         (6) PROVIDER PAYMENT.—Managed care plans and hospitals
  893  shall negotiate mutually acceptable rates, methods, and terms of
  894  payment. For rates, methods, and terms of payment negotiated
  895  after the contract between the agency and the plan is executed,
  896  plans shall pay hospitals, at a minimum, the rate the agency
  897  would have paid on the first day of the contract between the
  898  provider and the plan. Such payments to hospitals may not exceed
  899  120 percent of the rate the agency would have paid on the first
  900  day of the contract between the provider and the plan, unless
  901  specifically approved by the agency. Payment rates may be
  902  updated periodically.
  903         Section 22. Paragraph (b) of subsection (3) of section
  904  624.91, Florida Statutes, is amended to read:
  905         624.91 The Florida Healthy Kids Corporation Act.—
  906         (3) ELIGIBILITY FOR STATE-FUNDED ASSISTANCE.—Only the
  907  following individuals are eligible for state-funded assistance
  908  in paying Florida Healthy Kids premiums:
  909         (b) Notwithstanding s. 409.814, a legal alien aliens who is
  910  are enrolled in the Florida Healthy Kids program as of January
  911  31, 2004, who does do not qualify for Title XXI federal funds
  912  because he or she is they are not a lawfully residing child
  913  qualified aliens as defined in s. 409.811.
  914         Section 23. Subsection (6) of section 641.513, Florida
  915  Statutes, is amended, and subsection (7) is added to that
  916  section, to read:
  917         641.513 Requirements for providing emergency services and
  918  care.—
  919         (6) Reimbursement for services under this section provided
  920  to subscribers who are Medicaid recipients by a provider for
  921  whom no contract exists between the provider and the health
  922  maintenance organization shall be determined under chapter 409
  923  the lesser of:
  924         (a) The provider’s charges;
  925         (b) The usual and customary provider charges for similar
  926  services in the community where the services were provided;
  927         (c) The charge mutually agreed to by the entity and the
  928  provider within 60 days after submittal of the claim; or
  929         (d) The Medicaid rate.
  930         (7) Reimbursement for services under this section provided
  931  to subscribers who are enrolled in a health maintenance
  932  organization pursuant to s. 624.91 by a provider for whom no
  933  contract exists between the provider and the health maintenance
  934  organization shall be the lesser of:
  935         (a) The provider’s charges;
  936         (b) The usual and customary provider charges for similar
  937  services in the community where the services were provided;
  938         (c) The charge mutually agreed to by the entity and the
  939  provider within 60 days after submittal of the claim; or
  940         (d) The Medicaid rate.
  941         Section 24. Subject to federal approval and adoption of a
  942  contract amendment with the Agency for Health Care
  943  Administration, an organization that is currently authorized to
  944  provide Program of All-Inclusive Care for the Elderly (PACE)
  945  services in southeast Florida and that is granted authority
  946  under section 18 of chapter 2012-33, Laws of Florida, for up to
  947  150 enrollee slots to serve frail elders residing in Broward
  948  County may also use those PACE slots for frail elders residing
  949  in Miami-Dade County.
  950         Section 25. Subject to federal approval of the application
  951  to be a site for the Program of All-inclusive Care for the
  952  Elderly (PACE), the Agency for Health Care Administration shall
  953  contract with one private, not-for-profit hospice organization
  954  located in Escambia County that owns and manages health care
  955  organizations licensed in Hospice Service Areas 1, 2A, and 2B
  956  which provide comprehensive services, including, but not limited
  957  to, hospice and palliative care, to frail elders who reside in
  958  those Hospice Service Areas. The organization is exempt from the
  959  requirements of chapter 641, Florida Statutes. The agency, in
  960  consultation with the Department of Elderly Affairs and subject
  961  to the appropriation of funds by the Legislature, shall approve
  962  up to 100 initial enrollees in the Program of All-inclusive Care
  963  for the Elderly established by the organization to serve frail
  964  elders who reside in Hospice Service Areas 1, 2A, and 2B.
  965         Section 26. Except as otherwise expressly provided in this
  966  act and except for this section, which shall take effect upon
  967  this act becoming a law, this act shall take effect July 1,
  968  2016.

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