HB 1165 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
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 be reimbursed by the Agency 5
for Health Care Administration, managed care plans, 6
and subcontractors at a specified amount; amending s. 7
409.967, F.S.; requiring that Medicaid enrollees be 8
allowed their choice of certain qualified Me dicaid 9
providers; requiring the agency to adopt rules; 10
prohibiting a managed care plan from referring its 11
members to, or entering into a contract or an 12
arrangement to provide services with, a subcontractor 13
under certain circumstances; requiring that a 14
subcontractor of a managed care plan provide all 15
services in compliance with such contract or 16
arrangement and applicable federal waivers; 17
prohibiting a managed care plan from referring its 18
members to a subcontractor for covered services if the 19
subcontractor has an ownership interest or a profit -20
sharing arrangement with certain entities; providing 21
an effective date. 22
23
Be It Enacted by the Legislature of the State of Florida: 24
25
HB 1165 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
Section 1. Subsection (9) of section 409.908, Florida 26
Statutes, is amended to re ad: 27
409.908 Reimbursement of Medicaid providers. —Subject to 28
specific appropriations, the agency shall reimburse Medicaid 29
providers, in accordance with state and federal law, according 30
to methodologies set forth in the rules of the agency and in 31
policy manuals and handbooks incorporated by reference therein. 32
These methodologies may include fee schedules, reimbursement 33
methods based on cost reporting, negotiated fees, competitive 34
bidding pursuant to s. 287.057, and other mechanisms the agency 35
considers efficient and effective for purchasing services or 36
goods on behalf of recipients. If a provider is reimbursed based 37
on cost reporting and submits a cost report late and that cost 38
report would have been used to set a lower reimbursement rate 39
for a rate semester, then the provider's rate for that semester 40
shall be retroactively calculated using the new cost report, and 41
full payment at the recalculated rate shall be effected 42
retroactively. Medicare -granted extensions for filing cost 43
reports, if applicable, shall a lso apply to Medicaid cost 44
reports. Payment for Medicaid compensable services made on 45
behalf of Medicaid-eligible persons is subject to the 46
availability of moneys and any limitations or directions 47
provided for in the General Appropriations Act or chapter 2 16. 48
Further, nothing in this section shall be construed to prevent 49
or limit the agency from adjusting fees, reimbursement rates, 50
HB 1165 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
lengths of stay, number of visits, or number of services, or 51
making any other adjustments necessary to comply with the 52
availability of moneys and any limitations or directions 53
provided for in the General Appropriations Act, provided the 54
adjustment is consistent with legislative intent. 55
(9) A provider of home health care services or of medical 56
supplies and appliances must shall be reimbursed on the basis of 57
competitive bidding or for the lesser of the amount billed by 58
the provider or the agency's established maximum allowable 59
amount, except that, in the case of the rental or purchase of 60
durable medical equipment and complex rehabilitation technology, 61
the provider must be reimbursed by the agency, managed care 62
plans, and any subcontractors at an amount equal to 100 percent 63
of the total rental payments may not exceed the purchase price 64
of the equipment over its expected useful life o r the agency's 65
established maximum allowable amount , whichever amount is less . 66
Section 2. Paragraph (c) of subsection (2) of section 67
409.967, Florida Statutes, is amended, and paragraph (p) is 68
added to that subsection, to read: 69
409.967 Managed care p lan accountability.— 70
(2) The agency shall establish such contract requirements 71
as are necessary for the operation of the statewide managed care 72
program. In addition to any other provisions the agency may deem 73
necessary, the contract must require: 74
(c) Access.— 75
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
1. The agency shall establish specific standards for the 76
number, type, and regional distribution of providers in managed 77
care plan networks to ensure access to care for both adults and 78
children. Each plan must maintain a regionwide network of 79
providers in sufficient numbers to meet the access standards for 80
specific medical services for all recipients enrolled in the 81
plan. The exclusive use of mail -order pharmacies may not be 82
sufficient to meet network access standards. Consistent with the 83
standards established by the agency, provider networks may 84
include providers located outside the region. A plan may 85
contract with a new hospital facility before the date the 86
hospital becomes operational if the hospital has commenced 87
construction, will be licensed and operational by January 1, 88
2013, and a final order has issued in any civil or 89
administrative challenge. Each plan shall establish and maintain 90
an accurate and complete electronic database of contracted 91
providers, including information about licensure or 92
registration, locations and hours of operation, specialty 93
credentials and other certifications, specific performance 94
indicators, and such other information as the agency deems 95
necessary. The database must be available online to both the 96
agency and the public and have the capability to compare the 97
availability of providers to network adequacy standards and to 98
accept and display feedback from each provider's patients. Each 99
plan shall submit quarterly reports to the agency identifying 100
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the number of enrollees assigned to each primary care provider. 101
The agency shall conduct, or contract for, systematic and 102
continuous testing of the provider network databases maintained 103
by each plan to confirm accuracy, confirm that behavioral health 104
providers are accepting enrol lees, and confirm that enrollees 105
have access to behavioral health services. 106
2. Each managed care plan must publish any prescribed drug 107
formulary or preferred drug list on the plan's website in a 108
manner that is accessible to and searchable by enrollees an d 109
providers. The plan must update the list within 24 hours after 110
making a change. Each plan must ensure that the prior 111
authorization process for prescribed drugs is readily accessible 112
to health care providers, including posting appropriate contact 113
information on its website and providing timely responses to 114
providers. For Medicaid recipients diagnosed with hemophilia who 115
have been prescribed anti -hemophilic-factor replacement 116
products, the agency shall provide for those products and 117
hemophilia overlay servi ces through the agency's hemophilia 118
disease management program. 119
3. Managed care plans, and their fiscal agents or 120
intermediaries, must accept prior authorization requests for any 121
service electronically. 122
4. Managed care plans serving children in the car e and 123
custody of the Department of Children and Families must maintain 124
complete medical, dental, and behavioral health encounter 125
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information and participate in making such information available 126
to the department or the applicable contracted community -based 127
care lead agency for use in providing comprehensive and 128
coordinated case management. The agency and the department shall 129
establish an interagency agreement to provide guidance for the 130
format, confidentiality, recipient, scope, and method of 131
information to be made available and the deadlines for 132
submission of the data. The scope of information available to 133
the department shall be the data that managed care plans are 134
required to submit to the agency. The agency shall determine the 135
plan's compliance with stan dards for access to medical, dental, 136
and behavioral health services; the use of medications; and 137
follow up followup on all medically necessary services 138
recommended as a result of early and periodic screening, 139
diagnosis, and treatment. 140
5. Notwithstanding any other law, Medicaid enrollees, 141
including those enrolled in Medicaid managed care plans, must be 142
allowed their choice of any qualified Medicaid durable medical 143
equipment or complex rehabilitation technology provider. The 144
agency shall adopt rules to impl ement this subparagraph. 145
(p) Subcontractors.—A managed care plan may not refer its 146
members to or enter into a contract or an arrangement with a 147
subcontractor to provide services if the managed care plan or 148
the principal of the managed care plan has a com mon ownership 149
interest. A subcontractor of a managed care plan shall provide 150
HB 1165 2022
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
all services in compliance with the contract or arrangement and 151
the applicable federal waivers as reasonably necessary to 152
achieve the purpose for which such services are to be pro vided. 153
A managed care plan may not refer its members to a subcontractor 154
for covered services if the subcontractor has an ownership 155
interest or a profit -sharing arrangement with a provider, 156
another subcontractor, a third -party administrator, or a third -157
party entity. 158
Section 3. This act shall take effect July 1, 2022. 159