Florida Senate - 2017 COMMITTEE AMENDMENT
Bill No. CS for SB 670
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LEGISLATIVE ACTION
Senate . House
Comm: WD .
03/22/2017 .
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Appropriations Subcommittee on Health and Human Services (Bean)
recommended the following:
1 Senate Amendment (with title amendment)
2
3 Delete lines 27 - 131
4 and insert:
5 (a) A managed care plan may not enter into a contract with
6 a pharmacy benefits manager (PBM) to manage the prescription
7 drug coverage provided under the plan or to control the costs of
8 the prescription drug coverage under such plan unless:
9 1. The contract prevents the PBM from requiring that a plan
10 enrollee use a retail pharmacy or other pharmacy entity
11 providing pharmacy services in which the PBM has an ownership
12 interest or which has an ownership interest in the PBM, or the
13 contract provides an incentive to a plan enrollee to encourage
14 the enrollee to use a retail pharmacy, mail order pharmacy,
15 specialty pharmacy, or other pharmacy entity providing pharmacy
16 services in which the PBM has an ownership interest or which has
17 an ownership interest in the PBM, if the incentive is applicable
18 only to such pharmacies; and
19 2. The contract requires the PBM to update the maximum
20 allowable cost as defined by s. 465.1862(1)(a) every 7 calendar
21 days beginning on January 1 of each year, to accurately reflect
22 the market price of acquiring the drug.
23 (b) Plans must include all providers in the region which
24 that are classified by the agency as essential Medicaid
25 providers, unless the agency approves, in writing, an
26 alternative arrangement for securing the types of services
27 offered by the essential providers. Providers are essential for
28 serving Medicaid enrollees if they offer services that are not
29 available from any other provider within a reasonable access
30 standard, or if they provided a substantial share of the total
31 units of a particular service used by Medicaid patients within
32 the region during the last 3 years and the combined capacity of
33 other service providers in the region is insufficient to meet
34 the total needs of the Medicaid patients. The agency may not
35 classify physicians and other practitioners as essential
36 providers. The agency, at a minimum, shall determine which
37 providers in the following categories are essential Medicaid
38 providers:
39 1. Federally qualified health centers.
40 2. Statutory teaching hospitals as defined in s.
41 408.07(45).
42 3. Hospitals that are trauma centers as defined in s.
43 395.4001(14).
44 4. Hospitals located at least 25 miles from any other
45 hospital with similar services.
46
47 Managed care plans that have not contracted with all essential
48 providers in the region as of the first date of recipient
49 enrollment, or with whom an essential provider has terminated
50 its contract, must negotiate in good faith with such essential
51 providers for 1 year or until an agreement is reached, whichever
52 is first. Payments for services rendered by a nonparticipating
53 essential provider shall be made at the applicable Medicaid rate
54 as of the first day of the contract between the agency and the
55 plan. A rate schedule for all essential providers shall be
56 attached to the contract between the agency and the plan. After
57 1 year, managed care plans that are unable to contract with
58 essential providers shall notify the agency and propose an
59 alternative arrangement for securing the essential services for
60 Medicaid enrollees. The arrangement must rely on contracts with
61 other participating providers, regardless of whether those
62 providers are located within the same region as the
63 nonparticipating essential service provider. If the alternative
64 arrangement is approved by the agency, payments to
65 nonparticipating essential providers after the date of the
66 agency’s approval shall equal 90 percent of the applicable
67 Medicaid rate. Except for payment for emergency services, if the
68 alternative arrangement is not approved by the agency, payment
69 to nonparticipating essential providers shall equal 110 percent
70 of the applicable Medicaid rate.
71 (c)(b) Certain providers are statewide resources and
72 essential providers for all managed care plans in all regions.
73 All managed care plans must include these essential providers in
74 their networks. Statewide essential providers include:
75 1. Faculty plans of Florida medical schools.
76 2. Regional perinatal intensive care centers as defined in
77 s. 383.16(2).
78 3. Hospitals licensed as specialty children’s hospitals as
79 defined in s. 395.002(28).
80 4. Accredited and integrated systems serving medically
81 complex children which comprise separately licensed, but
82 commonly owned, health care providers delivering at least the
83 following services: medical group home, in-home and outpatient
84 nursing care and therapies, pharmacy services, durable medical
85 equipment, and Prescribed Pediatric Extended Care.
86
87 Managed care plans that have not contracted with all statewide
88 essential providers in all regions as of the first date of
89 recipient enrollment must continue to negotiate in good faith.
90 Payments to physicians on the faculty of nonparticipating
91 Florida medical schools shall be made at the applicable Medicaid
92 rate. Payments for services rendered by regional perinatal
93 intensive care centers shall be made at the applicable Medicaid
94 rate as of the first day of the contract between the agency and
95 the plan. Except for payments for emergency services, payments
96 to nonparticipating specialty children’s hospitals shall equal
97 the highest rate established by contract between that provider
98 and any other Medicaid managed care plan.
99 (d)(c) After 12 months of active participation in a plan’s
100 network, the plan may exclude any essential provider from the
101 network for failure to meet quality or performance criteria. If
102 the plan excludes an essential provider from the plan, the plan
103 must provide written notice to all recipients who have chosen
104 that provider for care. The notice shall be provided at least 30
105 days before the effective date of the exclusion. For purposes of
106 this paragraph, the term “essential provider” includes providers
107 determined by the agency to be essential Medicaid providers
108 under paragraph (b) (a) and the statewide essential providers
109 specified in paragraph (c) (b).
110 (e)(d) The applicable Medicaid rates for emergency services
111 paid by a plan under this section to a provider with which the
112 plan does not have an active contract shall be determined
113 according to s. 409.967(2)(b).
114 (f)(e) Each managed care plan must offer a network contract
115 to each home medical equipment and supplies provider in the
116 region which meets quality and fraud prevention and detection
117 standards established by the plan and which agrees to accept the
118 lowest price previously negotiated between the plan and another
119 such provider.
120
121 ================= T I T L E A M E N D M E N T ================
122 And the title is amended as follows:
123 Delete lines 3 - 10
124 and insert:
125 networks; amending s. 409.975, F.S.; prohibiting a
126 managed care plan from contracting with a pharmacy
127 benefits manager to manage the prescription drug
128 coverage provided under the plan unless certain
129 requirements are met; providing an