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