Florida Senate - 2022 SB 1540
By Senator Jones
35-00194B-22 20221540__
1 A bill to be entitled
2 An act relating to Medicaid managed care; amending s.
3 409.908, F.S.; requiring that the rental and purchase
4 of durable medical equipment and complex
5 rehabilitation technology by providers of home health
6 care services or medical supplies and appliances be
7 reimbursed by the Agency for Health Care
8 Administration, managed care plans, and subcontractors
9 at a specified amount; amending s. 409.967, F.S.;
10 requiring that Medicaid enrollees be allowed their
11 choice of certain qualified Medicaid providers;
12 requiring the agency to adopt rules; prohibiting a
13 managed care plan from referring its members to, or
14 entering into a contract or an arrangement to provide
15 services with, a subcontractor under certain
16 circumstances; requiring that a subcontractor of a
17 managed care plan provide all services in compliance
18 with such contract or arrangement and applicable
19 federal waivers; prohibiting a managed care plan from
20 referring its members to a subcontractor for covered
21 services if the subcontractor has an ownership
22 interest or a profit-sharing arrangement with certain
23 entities; providing an effective date.
24
25 Be It Enacted by the Legislature of the State of Florida:
26
27 Section 1. Subsection (9) of section 409.908, Florida
28 Statutes, is amended to read:
29 409.908 Reimbursement of Medicaid providers.—Subject to
30 specific appropriations, the agency shall reimburse Medicaid
31 providers, in accordance with state and federal law, according
32 to methodologies set forth in the rules of the agency and in
33 policy manuals and handbooks incorporated by reference therein.
34 These methodologies may include fee schedules, reimbursement
35 methods based on cost reporting, negotiated fees, competitive
36 bidding pursuant to s. 287.057, and other mechanisms the agency
37 considers efficient and effective for purchasing services or
38 goods on behalf of recipients. If a provider is reimbursed based
39 on cost reporting and submits a cost report late and that cost
40 report would have been used to set a lower reimbursement rate
41 for a rate semester, then the provider’s rate for that semester
42 shall be retroactively calculated using the new cost report, and
43 full payment at the recalculated rate shall be effected
44 retroactively. Medicare-granted extensions for filing cost
45 reports, if applicable, shall also apply to Medicaid cost
46 reports. Payment for Medicaid compensable services made on
47 behalf of Medicaid-eligible persons is subject to the
48 availability of moneys and any limitations or directions
49 provided for in the General Appropriations Act or chapter 216.
50 Further, nothing in this section shall be construed to prevent
51 or limit the agency from adjusting fees, reimbursement rates,
52 lengths of stay, number of visits, or number of services, or
53 making any other adjustments necessary to comply with the
54 availability of moneys and any limitations or directions
55 provided for in the General Appropriations Act, provided the
56 adjustment is consistent with legislative intent.
57 (9) A provider of home health care services or of medical
58 supplies and appliances must shall be reimbursed on the basis of
59 competitive bidding or for the lesser of the amount billed by
60 the provider or the agency’s established maximum allowable
61 amount, except that, in the case of the rental or purchase of
62 durable medical equipment and complex rehabilitation technology,
63 the provider must be reimbursed by the agency, managed care
64 plans, and any subcontractors at an amount equal to 100 percent
65 of the total rental payments may not exceed the purchase price
66 of the equipment over its expected useful life or the agency’s
67 established maximum allowable amount, whichever amount is less.
68 Section 2. Paragraph (c) of subsection (2) of section
69 409.967, Florida Statutes, is amended, and paragraph (p) is
70 added to that subsection, to read:
71 409.967 Managed care plan accountability.—
72 (2) The agency shall establish such contract requirements
73 as are necessary for the operation of the statewide managed care
74 program. In addition to any other provisions the agency may deem
75 necessary, the contract must require:
76 (c) Access.—
77 1. The agency shall establish specific standards for the
78 number, type, and regional distribution of providers in managed
79 care plan networks to ensure access to care for both adults and
80 children. Each plan must maintain a regionwide network of
81 providers in sufficient numbers to meet the access standards for
82 specific medical services for all recipients enrolled in the
83 plan. The exclusive use of mail-order pharmacies may not be
84 sufficient to meet network access standards. Consistent with the
85 standards established by the agency, provider networks may
86 include providers located outside the region. A plan may
87 contract with a new hospital facility before the date the
88 hospital becomes operational if the hospital has commenced
89 construction, will be licensed and operational by January 1,
90 2013, and a final order has issued in any civil or
91 administrative challenge. Each plan shall establish and maintain
92 an accurate and complete electronic database of contracted
93 providers, including information about licensure or
94 registration, locations and hours of operation, specialty
95 credentials and other certifications, specific performance
96 indicators, and such other information as the agency deems
97 necessary. The database must be available online to both the
98 agency and the public and have the capability to compare the
99 availability of providers to network adequacy standards and to
100 accept and display feedback from each provider’s patients. Each
101 plan shall submit quarterly reports to the agency identifying
102 the number of enrollees assigned to each primary care provider.
103 The agency shall conduct, or contract for, systematic and
104 continuous testing of the provider network databases maintained
105 by each plan to confirm accuracy, confirm that behavioral health
106 providers are accepting enrollees, and confirm that enrollees
107 have access to behavioral health services.
108 2. Each managed care plan must publish any prescribed drug
109 formulary or preferred drug list on the plan’s website in a
110 manner that is accessible to and searchable by enrollees and
111 providers. The plan must update the list within 24 hours after
112 making a change. Each plan must ensure that the prior
113 authorization process for prescribed drugs is readily accessible
114 to health care providers, including posting appropriate contact
115 information on its website and providing timely responses to
116 providers. For Medicaid recipients diagnosed with hemophilia who
117 have been prescribed anti-hemophilic-factor replacement
118 products, the agency shall provide for those products and
119 hemophilia overlay services through the agency’s hemophilia
120 disease management program.
121 3. Managed care plans, and their fiscal agents or
122 intermediaries, must accept prior authorization requests for any
123 service electronically.
124 4. Managed care plans serving children in the care and
125 custody of the Department of Children and Families must maintain
126 complete medical, dental, and behavioral health encounter
127 information and participate in making such information available
128 to the department or the applicable contracted community-based
129 care lead agency for use in providing comprehensive and
130 coordinated case management. The agency and the department shall
131 establish an interagency agreement to provide guidance for the
132 format, confidentiality, recipient, scope, and method of
133 information to be made available and the deadlines for
134 submission of the data. The scope of information available to
135 the department shall be the data that managed care plans are
136 required to submit to the agency. The agency shall determine the
137 plan’s compliance with standards for access to medical, dental,
138 and behavioral health services; the use of medications; and
139 follow up followup on all medically necessary services
140 recommended as a result of early and periodic screening,
141 diagnosis, and treatment.
142 5. Notwithstanding any other law, Medicaid enrollees,
143 including those enrolled in Medicaid managed care plans, must be
144 allowed their choice of any qualified Medicaid durable medical
145 equipment or complex rehabilitation technology provider. The
146 agency shall adopt rules to implement this subparagraph.
147 (p) Subcontractors.—A managed care plan may not refer its
148 members to or enter into a contract or an arrangement with a
149 subcontractor to provide services if the managed care plan or
150 the principal of the managed care plan has a common ownership
151 interest. A subcontractor of a managed care plan shall provide
152 all services in compliance with the contract or arrangement and
153 the applicable federal waivers as reasonably necessary to
154 achieve the purpose for which such services are to be provided.
155 A managed care plan may not refer its members to a subcontractor
156 for covered services if the subcontractor has an ownership
157 interest or a profit-sharing arrangement with a provider,
158 another subcontractor, a third-party administrator, or a third
159 party entity.
160 Section 3. This act shall take effect July 1, 2022.