Florida Statutes 409.906 – Optional Medicaid services
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Subject to specific appropriations, the agency may make payments for services which are optional to the state under Title XIX of the Social Security Act and are furnished by Medicaid providers to recipients who are determined to be eligible on the dates on which the services were provided. Any optional service that is provided shall be provided only when medically necessary and in accordance with state and federal law. Optional services rendered by providers in mobile units to Medicaid recipients may be restricted or prohibited by the agency. Nothing in this section shall be construed to prevent or limit the agency from adjusting fees, reimbursement rates, lengths of stay, number of visits, or number of services, or making any other adjustments necessary to comply with the availability of moneys and any limitations or directions provided for in the General Appropriations Act or chapter 216. If necessary to safeguard the state’s systems of providing services to elderly and disabled persons and subject to the notice and review provisions of s. 216.177, the Governor may direct the Agency for Health Care Administration to amend the Medicaid state plan to delete the optional Medicaid service known as “Intermediate Care Facilities for the Developmentally Disabled.” Optional services may include:
(1) ADULT DENTAL SERVICES.–
(a) The agency may pay for medically necessary, emergency dental procedures to alleviate pain or infection. Emergency dental care shall be limited to emergency oral examinations, necessary radiographs, extractions, and incision and drainage of abscess, for a recipient who is 21 years of age or older.
Terms Used In Florida Statutes 409.906
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- Contract: A legal written agreement that becomes binding when signed.
- Donor: The person who makes a gift.
- Evidence: Information presented in testimony or in documents that is used to persuade the fact finder (judge or jury) to decide the case for one side or the other.
- Fraud: Intentional deception resulting in injury to another.
(b) The agency may pay for full or partial dentures, the procedures required to seat full or partial dentures, and the repair and reline of full or partial dentures, provided by or under the direction of a licensed dentist, for a recipient who is 21 years of age or older.
(c) However, Medicaid will not provide reimbursement for dental services provided in a mobile dental unit, except for a mobile dental unit:
1. Owned by, operated by, or having a contractual agreement with the Department of Health and complying with Medicaid’s county health department clinic services program specifications as a county health department clinic services provider.
2. Owned by, operated by, or having a contractual arrangement with a federally qualified health center and complying with Medicaid’s federally qualified health center specifications as a federally qualified health center provider.
3. Rendering dental services to Medicaid recipients, 21 years of age and older, at nursing facilities.
4. Owned by, operated by, or having a contractual agreement with a state-approved dental educational institution.
(2) ADULT HEALTH SCREENING SERVICES.–The agency may pay for an annual routine physical examination, conducted by or under the direction of a licensed physician, for a recipient age 21 or older, without regard to medical necessity, in order to detect and prevent disease, disability, or other health condition or its progression.
(3) AMBULATORY SURGICAL CENTER SERVICES.–The agency may pay for services provided to a recipient in an ambulatory surgical center licensed under part I of chapter 395, by or under the direction of a licensed physician or dentist.
(4) BIRTH CENTER SERVICES.–The agency may pay for examinations and delivery, recovery, and newborn assessment, and related services, provided in a licensed birth center staffed with licensed physicians, certified nurse midwives, and midwives licensed in accordance with chapter 467, to a recipient expected to experience a low-risk pregnancy and delivery.
(5) CASE MANAGEMENT SERVICES.–The agency may pay for primary care case management services rendered to a recipient pursuant to a federally approved waiver, and targeted case management services for specific groups of targeted recipients, for which funding has been provided and which are rendered pursuant to federal guidelines. The agency is authorized to limit reimbursement for targeted case management services in order to comply with any limitations or directions provided for in the General Appropriations Act.
(6) CHILDREN’S DENTAL SERVICES.–The agency may pay for diagnostic, preventive, or corrective procedures, including orthodontia in severe cases, provided to a recipient under age 21, by or under the supervision of a licensed dentist. The agency may also reimburse a health access setting as defined in s. 466.003 for the remediable tasks that a licensed dental hygienist is authorized to perform under s. 466.024(2). Services provided under this program include treatment of the teeth and associated structures of the oral cavity, as well as treatment of disease, injury, or impairment that may affect the oral or general health of the individual. However, Medicaid will not provide reimbursement for dental services provided in a mobile dental unit, except for a mobile dental unit:
(a) Owned by, operated by, or having a contractual agreement with the Department of Health and complying with Medicaid’s county health department clinic services program specifications as a county health department clinic services provider.
(b) Owned by, operated by, or having a contractual arrangement with a federally qualified health center and complying with Medicaid’s federally qualified health center specifications as a federally qualified health center provider.
(c) Rendering dental services to Medicaid recipients, 21 years of age and older, at nursing facilities.
(d) Owned by, operated by, or having a contractual agreement with a state-approved dental educational institution.
(7) CHIROPRACTIC SERVICES.–The agency may pay for manual manipulation of the spine and initial services, screening, and X rays provided to a recipient by a licensed chiropractic physician.
(8) COMMUNITY MENTAL HEALTH SERVICES.–
(a) The agency may pay for rehabilitative services provided to a recipient by a mental health or substance abuse provider under contract with the agency or the Department of Children and Families to provide such services. Those services which are psychiatric in nature shall be rendered or recommended by a psychiatrist, and those services which are medical in nature shall be rendered or recommended by a physician or psychiatrist. The agency must develop a provider enrollment process for community mental health providers which bases provider enrollment on an assessment of service need. The provider enrollment process shall be designed to control costs, prevent fraud and abuse, consider provider expertise and capacity, and assess provider success in managing utilization of care and measuring treatment outcomes. Providers will be selected through a competitive procurement or selective contracting process. In addition to other community mental health providers, the agency shall consider for enrollment mental health programs licensed under chapter 395 and group practices licensed under chapter 458, chapter 459, chapter 490, or chapter 491. The agency is also authorized to continue operation of its behavioral health utilization management program and may develop new services if these actions are necessary to ensure savings from the implementation of the utilization management system. The agency shall coordinate the implementation of this enrollment process with the Department of Children and Families and the Department of Juvenile Justice. The agency is authorized to utilize diagnostic criteria in setting reimbursement rates, to preauthorize certain high-cost or highly utilized services, to limit or eliminate coverage for certain services, or to make any other adjustments necessary to comply with any limitations or directions provided for in the General Appropriations Act.
(b) The agency is authorized to implement reimbursement and use management reforms in order to comply with any limitations or directions in the General Appropriations Act, which may include, but are not limited to: prior authorization of treatment and service plans; prior authorization of services; enhanced use review programs for highly used services; and limits on services for those determined to be abusing their benefit coverages.
(9) DIALYSIS FACILITY SERVICES.–Subject to specific appropriations being provided for this purpose, the agency may pay a dialysis facility that is approved as a dialysis facility in accordance with Title XVIII of the Social Security Act, for dialysis services that are provided to a Medicaid recipient under the direction of a physician licensed to practice medicine or osteopathic medicine in this state, including dialysis services provided in the recipient’s home by a hospital-based or freestanding dialysis facility.
(10) DURABLE MEDICAL EQUIPMENT.–The agency may authorize and pay for certain durable medical equipment and supplies provided to a Medicaid recipient as medically necessary.
(11) HEALTHY START SERVICES.–The agency may pay for a continuum of risk-appropriate medical and psychosocial services for the Healthy Start program in accordance with a federal waiver. The agency may not implement the federal waiver unless the waiver permits the state to limit enrollment or the amount, duration, and scope of services to ensure that expenditures will not exceed funds appropriated by the Legislature or available from local sources. If the Health Care Financing Administration does not approve a federal waiver for Healthy Start services, the agency, in consultation with the Department of Health and the Florida Association of Healthy Start Coalitions, is authorized to establish a Medicaid certified-match program for Healthy Start services. Participation in the Healthy Start certified-match program shall be voluntary, and reimbursement shall be limited to the federal Medicaid share to Medicaid-enrolled Healthy Start coalitions for services provided to Medicaid recipients. The agency shall take no action to implement a certified-match program without ensuring that the amendment and review requirements of ss. 216.177 and 216.181 have been met.
(12) HEARING SERVICES.–The agency may pay for hearing and related services, including hearing evaluations, hearing aid devices, dispensing of the hearing aid, and related repairs, if provided to a recipient by a licensed hearing aid specialist, otolaryngologist, otologist, audiologist, or physician.
(13) HOME AND COMMUNITY-BASED SERVICES.–
(a) The agency may pay for home-based or community-based services that are rendered to a recipient in accordance with a federally approved waiver program. The agency may limit or eliminate coverage for certain services, preauthorize high-cost or highly utilized services, or make any other adjustments necessary to comply with any limitations or directions provided for in the General Appropriations Act.
(b) The agency may implement a utilization management program designed to prior-authorize home and community-based service plans and includes, but is not limited to, assessing proposed quantity and duration of services and monitoring ongoing service use by participants in the program. The agency is authorized to competitively procure a qualified organization to provide utilization management of home and community-based services. The agency is authorized to seek any federal waivers to implement this initiative.
(c) The agency shall request federal approval to develop a system to require payment of premiums or other cost sharing by the parents of a child who is being served by a waiver under this subsection if the adjusted household income is greater than 100 percent of the federal poverty level. The amount of the premium or cost sharing shall be calculated using a sliding scale based on the size of the family, the amount of the parent’s adjusted gross income, and the federal poverty guidelines. The premium and cost-sharing system developed by the agency shall not adversely affect federal funding to the state. After the agency receives federal approval, the Department of Children and Families may collect income information from parents of children who will be affected by this paragraph.
(d) The agency shall seek federal approval to pay for flexible services for persons with severe mental illness or substance use disorders, including, but not limited to, temporary housing assistance. Payments may be made as enhanced capitation rates or incentive payments to managed care plans that meet the requirements of s. 409.968(4).
(14) HOSPICE CARE SERVICES.–The agency may pay for all reasonable and necessary services for the palliation or management of a recipient’s terminal illness, if the services are provided by a hospice that is licensed under part IV of chapter 400 and meets Medicare certification requirements.
(15) INTERMEDIATE CARE FACILITY FOR THE DEVELOPMENTALLY DISABLED SERVICES.–The agency may pay for health-related care and services provided on a 24-hour-a-day basis by a facility licensed and certified as a Medicaid Intermediate Care Facility for the Developmentally Disabled, for a recipient who needs such care because of a developmental disability. Payment shall not include bed-hold days except in facilities with occupancy rates of 95 percent or greater. The agency is authorized to seek any federal waiver approvals to implement this policy. The agency shall seek federal approval to implement a payment rate for Medicaid intermediate care facilities serving individuals with developmental disabilities, severe maladaptive behaviors, severe maladaptive behaviors and co-occurring complex medical conditions, or a dual diagnosis of developmental disability and mental illness.
(16) INTERMEDIATE CARE SERVICES.–The agency may pay for 24-hour-a-day intermediate care nursing and rehabilitation services rendered to a recipient in a nursing facility licensed under part II of chapter 400, if the services are ordered by and provided under the direction of a physician.
(17) OPTOMETRIC SERVICES.–The agency may pay for services provided to a recipient, including examination, diagnosis, treatment, and management, related to ocular pathology, if the services are provided by a licensed optometrist or physician.
(18) PHYSICIAN ASSISTANT SERVICES.–The agency may pay for all services provided to a recipient by a physician assistant licensed under s. 458.347 or s. 459.022. Reimbursement for such services must be not less than 80 percent of the reimbursement that would be paid to a physician who provided the same services.
(19) PODIATRIC SERVICES.–The agency may pay for services, including diagnosis and medical, surgical, palliative, and mechanical treatment, related to ailments of the human foot and lower leg, if provided to a recipient by a podiatric physician licensed under state law.
(20) PRESCRIBED DRUG SERVICES.–The agency may pay for medications that are prescribed for a recipient by a physician or other licensed practitioner of the healing arts authorized to prescribe medications and that are dispensed to the recipient by a licensed pharmacist or physician in accordance with applicable state and federal law.
(21) REGISTERED NURSE FIRST ASSISTANT SERVICES.–The agency may pay for all services provided to a recipient by a registered nurse first assistant as described in s. 464.027. Reimbursement for such services may not be less than 80 percent of the reimbursement that would be paid to a physician providing the same services.
(22) STATE HOSPITAL SERVICES.–The agency may pay for all-inclusive psychiatric inpatient hospital care provided to a recipient age 65 or older in a state mental hospital.
(23) VISUAL SERVICES.–The agency may pay for visual examinations, eyeglasses, and eyeglass repairs for a recipient if they are prescribed by a licensed physician specializing in diseases of the eye or by a licensed optometrist. Eyeglass frames for adult recipients shall be limited to one pair per recipient every 2 years, except a second pair may be provided during that period after prior authorization. Eyeglass lenses for adult recipients shall be limited to one pair per year except a second pair may be provided during that period after prior authorization.
(24) CHILD-WELFARE-TARGETED CASE MANAGEMENT.–The Agency for Health Care Administration, in consultation with the Department of Children and Families, may establish a targeted case-management project in those counties identified by the Department of Children and Families and for all counties with a community-based child welfare project, as authorized under s. 409.987 which have been specifically approved by the department. The covered group of individuals who are eligible to receive targeted case management include children who are eligible for Medicaid; who are between the ages of birth through 21; and who are under protective supervision or postplacement supervision, under foster-care supervision, or in shelter care or foster care. The number of individuals who are eligible to receive targeted case management is limited to the number for whom the Department of Children and Families has matching funds to cover the costs. The general revenue funds required to match the funds for services provided by the community-based child welfare projects are limited to funds available for services described under s. 409.990. The Department of Children and Families may transfer the general revenue matching funds as billed by the Agency for Health Care Administration.
(25) ASSISTIVE-CARE SERVICES.–The agency may pay for assistive-care services provided to recipients with functional or cognitive impairments residing in assisted living facilities, adult family-care homes, or residential treatment facilities. These services may include health support, assistance with the activities of daily living and the instrumental acts of daily living, assistance with medication administration, and arrangements for health care.
(26) HOME AND COMMUNITY-BASED SERVICES FOR AUTISM SPECTRUM DISORDER AND OTHER DEVELOPMENTAL DISABILITIES.–The agency is authorized to seek federal approval through a Medicaid waiver or a state plan amendment for the provision of occupational therapy, speech therapy, physical therapy, behavior analysis, and behavior assistant services to individuals who are 5 years of age and under and have a diagnosed developmental disability as defined in s. 393.063, autism spectrum disorder as defined in s. 627.6686, or Down syndrome, a genetic disorder caused by the presence of extra chromosomal material on chromosome 21. Causes of the syndrome may include Trisomy 21, Mosaicism, Robertsonian Translocation, and other duplications of a portion of chromosome 21. Coverage for such services shall be limited to $36,000 annually and may not exceed $108,000 in total lifetime benefits. The agency shall submit an annual report on January 1 to the President of the Senate, the Speaker of the House of Representatives, and the relevant committees of the Senate and the House of Representatives regarding progress on obtaining federal approval and recommendations for the implementation of these home and community-based services. The agency may not implement this subsection without prior legislative approval.
(27) ANESTHESIOLOGIST ASSISTANT SERVICES.–The agency may pay for all services provided to a recipient by an anesthesiologist assistant licensed under s. 458.3475 or s. 459.023. Reimbursement for such services must be not less than 80 percent of the reimbursement that would be paid to a physician who provided the same services.
(28) DONOR HUMAN MILK BANK SERVICES.–The agency may pay for the provision of donor human milk and human milk products derived therefrom for inpatient use, for which a licensed physician, nurse practitioner, physician assistant, or dietitian has issued an order for an infant who is medically or physically unable to receive maternal breast milk or to breastfeed or whose mother is medically or physically unable to produce maternal breast milk or breastfeed. Such infant must have a documented birth weight of 1,800 grams or less; have a congenital or acquired condition and be at high risk for developing a feeding intolerance, necrotizing enterocolitis, or an infection; or otherwise have a medical indication for a human milk diet. The agency shall adopt rules that include, but are not limited to, eligible providers of donor human milk and donor human milk derivates. The agency may seek federal approval necessary to implement this subsection.
(29) BIOMARKER TESTING SERVICES.–
(a) The agency may pay for biomarker testing for the purposes of diagnosis, treatment, appropriate management, or ongoing monitoring of a recipient’s disease or condition to guide treatment decisions if medical and scientific evidence indicates that the biomarker testing provides clinical utility to the recipient. Such medical and scientific evidence includes, but is not limited to:
1. A labeled indication for a test approved or cleared by the United States Food and Drug Administration;
2. An indicated test for a drug approved by the United States Food and Drug Administration;
3. A national coverage determination made by the Centers for Medicare and Medicaid Services or a local coverage determination made by the Medicare Administrative Contractor; or
4. A nationally recognized clinical practice guideline. As used in this subparagraph, the term “nationally recognized clinical practice guideline” means an evidence-based clinical practice guideline developed by independent organizations or medical professional societies using a transparent methodology and reporting structure and with a conflict-of-interest policy. Guidelines developed by such organizations or societies establish standards of care informed by a systematic review of evidence and an assessment of the benefits and costs of alternative care options and include recommendations intended to optimize patient care.
(b) As used in this subsection, the term:
1. “Biomarker” means a defined characteristic that is measured as an indicator of normal biological processes, pathogenic processes, or responses to an exposure or intervention, including therapeutic interventions. The term includes, but is not limited to, molecular, histologic, radiographic, or physiologic characteristics but does not include an assessment of how a patient feels, functions, or survives.
2. “Biomarker testing” means an analysis of a patient’s tissue, blood, or other biospecimen for the presence of a biomarker. The term includes, but is not limited to, single analyte tests, multiplex panel tests, protein expression, and whole exome, whole genome, and whole transcriptome sequencing performed at a participating in-network laboratory facility that is certified pursuant to the federal Clinical Laboratory Improvement Amendment (CLIA) or that has obtained a CLIA Certificate of Waiver by the United States Food and Drug Administration for the tests.
3. “Clinical utility” means the test result provides information that is used in the formulation of a treatment or monitoring strategy that informs a patient’s outcome and impacts the clinical decision.
(c) A recipient and participating provider shall have access to a clear and convenient process to request authorization for biomarker testing as provided under this subsection. Such process shall be made readily accessible to all recipients and participating providers online.
(d) This subsection does not require coverage of biomarker testing for screening purposes.
(e) The agency may seek federal approval necessary to implement this subsection.