The Florida Senate
BILL ANALYSIS AND FISCAL IMPACT STATEMENT
(This document is based on the provisions contained in the legislation as of the latest date listed below.)
Prepared By: The Professional Staff of the Committee on Health Policy
BILL: SB 1258
INTRODUCER: Senator Jones
SUBJECT: Managed Care Plan Performance
DATE: January 25, 2022
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Smith Brown HP Favorable
2. BI
3. RC
I. Summary:
SB 1258 statutorily requires managed care plans contracted with the Agency for Health Care
Administration (AHCA) under the Statewide Medicaid Managed Care (SMMC) program to
collect and annually report an expanded set of performance measures, including Healthcare
Effectiveness Data and Information Set (HEDIS) measures, the federal Core Set of Children’s
Health Care Quality measures, and the federal Core Set of Adult Health Care Quality
performance measures, as specified by the AHCA.
Beginning in calendar year 2025, the bill requires each managed care plan to collect and report
all of the Adult Core Set behavioral health measures, which are not currently required by statute
to be reported. Beginning in calendar year 2026, the bill requires each managed care plan to
stratify all performance measure data by recipient age, race, ethnicity, primary language, sex, and
disability status.
The bill poses an indeterminate negative fiscal impact to the Florida Medicaid Program and its
managed care plans.
The bill provides an effective date of July 1, 2022.
II. Present Situation:
Florida Medicaid Program
The AHCA is responsible for the administration of the Florida Medicaid program, authorized
under Title XIX of the Social Security Act.
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This authority includes establishing and maintaining
a Medicaid state plan approved by the Centers for Medicare & Medicaid Services (CMS) and
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Section 409.902, F.S.
REVISED: BILL: SB 1258 Page 2
maintaining any Medicaid waivers needed to operate the Florida Medicaid program as directed
by the Legislature.
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Florida Medicaid enrollees generally receive benefits through one of two service-delivery
systems: fee-for-service (FFS) or managed care. Under FFS, health care providers are paid by the
state Medicaid program for each service provided to a Medicaid enrollee. In Florida, the majority
of Medicaid recipients receive their services through a managed care plan contracted with the
AHCA under the SMMC program. The state pays the managed care plans a capitation payment,
or fixed monthly payment, per recipient enrolled in the managed care plan.
Managed Care Plan Performance Measure Reporting
The AHCA monitors contracted manage care plan performance through a combination of
performance measures developed by the National Committee for Quality Assurance (NCQA),
the federal CMS, and the AHCA itself.
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The NCQA develops the HEDIS as a standardized tool to measure the performance of health
plans. More than 90 percent of health plans in America use the HEDIS tool to measure
performance on important dimensions of care and service, making it convenient to compare plan
performance.
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Current law requires managed care plans participating in the SMMC program to
collect and report HEDIS measures specified by the AHCA on an annual basis and to post the
information its website in a manner that allows recipients to reliably compare the performance of
available plans.
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For calendar year 2020, the managed care plans were required to report 27 HEDIS measures
related to medical care and nine Child and Adult Core Set measures, a total of 36 measures.
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Many of these measures include sub-measures. The total number of performance measure rates,
or lines of data that must currently be reported for the measures and sub-measures is 192.
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Each managed care plan operates in at least one region of the state and several managed care
plans operate in all 11 regions. For calendar year 2020 performance measure reporting (which
occurred in 2021), the AHCA required managed care plans to provide regional breakouts in
addition to the statewide rates for most of the HEDIS and Child and Adult Core Set measures
that it currently requires plans to report.
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The AHCA required the regional stratifications to
identify potential differences in plan performance by region and to better target areas where
improvement may be needed.
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2
Medicaid.gov, Medicaid State Plan Amendments, available at https://www.medicaid.gov/medicaid/medicaid-state-plan-
amendments/index.html (last visited Jan. 22, 2022).
3
Agency for Health Care Administration, Performance Measure Data Submissions for Medicaid,
https://ahca.myflorida.com/medicaid/quality_mc/submission.shtml (last visited January 22, 2022).
4
U.S. Department of Health and Human Services, Healthcare Effectiveness Data and Information Set,
https://www.healthypeople.gov/2020/data-source/healthcare-effectiveness-data-and-information-set (last visited January 22,
2022).
5
Section 409.967(2)(f)2., F.S.
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Agency for Health Care Administration, Agency Analysis of HB 855, Dec. 16, 2021 (on file with Committee on Health
Policy).
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Id. BILL: SB 1258 Page 3
For plans operating in only one region, the base number of 192 performance measure rates,
or lines of data, were required to be reported since the plan’s statewide and regional results
are the same.
For a plan operating in two regions of the state, the base number of 192 performance measure
rates is multiplied by three, as the plan will be reporting a statewide rate and separate rates
for each of the two regions. In this case, 576 performance measure rates were required to be
reported.
For a plan operating in all 11 regions of the state, the base number of 192 performance
measure rates is multiplied by 12, as the plan will be reporting a statewide rate and separate
rates for each of the 11 regions. In this case, 2,304 performance measure rates were required
to be reported.
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The AHCA reports that managed care plans have indicated that the addition of the regional
stratifications they reported for calendar year 2020 combined with the race and ethnicity
stratifications added a substantial workload for them and their software vendors and auditors.
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The AHCA requires the plans to have their performance measures audited and certified by
NCQA-certified HEDIS auditors, which includes any stratifications required by the AHCA.
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III. Effect of Proposed Changes:
The bill amends s. 409.967(2)(f), F.S., to require managed care plans to collect and annually
report HEDIS measures, the federal Core Set of Children’s Health Care Quality measures, and
the federal Core Set of Adult Health Care Quality performance measures, as specified by the
AHCA. Section 409.967(2)(f), F.S., currently requires managed care plans to collect and
annually report HEDIS measures. The AHCA currently requires plans participating in the MMA
program to report a selection of measures from both the Adult and Child Core Sets in its
contracts with those plans.
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Under the bill, each plan must collect and report the Adult Core Set behavioral health measures,
which are not currently required by statute to be reported, beginning with data reports for the
2025 calendar year. Each plan must stratify reported measures by age, sex, race, ethnicity,
primary language, and whether the enrollee received a Social Security Administration
determination of disability for purposes of Supplemental Security Income, beginning with data
reports for the 2026 calendar year. The bill requires each managed care plan to post all these
measures, and the corresponding stratified data, to the plan’s website.
Although the managed care plans have recently added regional and race and ethnicity
stratifications to several of the measures they reported on this year, this bill will require them to
add race and ethnicity stratifications to all measures, and add stratifications in four additional
areas (age, sex, primary language, and disability status) to all AHCA-required measures.
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Id. BILL: SB 1258 Page 4
The bill updates a reference to the “HEDIS” data set which was formerly referred to as “Health
Plan Employer Data and Information Set” but is now referred to by the NCQA as the
“Healthcare Effectiveness Data and Information Set.”
The bill also corrects a grammatical error in current law by changing “s.” to its plural form “ss.”
The bill provides an effective date of July 1, 2022.
IV. Constitutional Issues:
A. Municipality/County Mandates Restrictions:
None.
B. Public Records/Open Meetings Issues:
None.
C. Trust Funds Restrictions:
None.
D. State Tax or Fee Increases:
None.
E. Other Constitutional Issues:
None.
V. Fiscal Impact Statement:
A. Tax/Fee Issues:
None.
B. Private Sector Impact:
The bill increases the stratifications and the volume of performance measure rates to be
calculated, audited, and reported. The AHCA reports that this will result in increased
operational and administrative costs for the managed care plans due to increased
workload for the plans and increased costs for the plans’ contracted NCQA-certified
auditors and NCQA-certified HEDIS software vendors.
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Id. BILL: SB 1258 Page 5
C. Government Sector Impact
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:
The changes required by this bill would not need to be implemented until calendar year
2025. As such, the current Statewide Medicaid Managed Care (SMMC) contracts would
not be affected and would not require an amendment. However, these requirements and
expectations would need to be included in the next procurement and in the rates for the
next contracts. The exact fiscal impact to the plans and thus, to the rates, is unknown at
this time.
SB 1258 poses a moderate operational and fiscal impact on the Florida Medicaid
Program. The AHCA reports that the increase in the volume of rates being reported to the
AHCA under the bill will increase staff workload and will require one additional FTE.
The total cost to the AHCA for the additional FTE is $79,930. This amount includes non-
recurring expenditures, salary, and benefits for the position. The cost of the additional
FTE is funded by the Medical Care Trust Fund. The state’s portion of the total cost is
$39,965.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends section 409.967 of the Florida Statutes.
IX. Additional Information:
A. Committee Substitute – Statement of Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
None.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.
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