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: CS/SB 306
INTRODUCER: Health Policy Committee and Senators Sharief and Gaetz
SUBJECT: Managed Care Plan Network Access
DATE: April 3, 2025
ANALYST STAFF DIRECTOR REFERENCE ACTION
1. Morgan Brown HP Fav/CS
2. AHS
3. FP
Please see Section IX. for Additional Information:
COMMITTEE SUBSTITUTE - Substantial Changes
I. Summary:
CS/SB 306 amends s. 409.967, F.S., to require the Florida Agency for Health Care
Administration (AHCA) to establish specific standards to ensure enrollees have access to
network providers during state holidays and outside regular business hours.
The bill provides an effective date of July 1, 2025.
II. Present Situation:
The Florida Agency for Health Care Administration
The Florida Agency for Health Care Administration (AHCA) is created under s. 20.42, F.S., to
be the chief health policy and planning entity for the state, responsible for health facility
licensure, inspection, and regulatory enforcement,
1
as well as the administration of Florida’s
Medicaid program.
2
1
Florida Agency for Health Care Administration, Health Quality Assurance, available at https://ahca.myflorida.com/health-
quality-assurance (last visited Mar. 27, 2025).
2
Section 409.902, F.S.
REVISED: BILL: CS/SB 306 Page 2
The Florida Medicaid Program
The Medicaid program is a voluntary, federal-state program that finances health coverage for
individuals, including eligible low-income adults, children, pregnant women, elderly adults, and
persons with disabilities.
3
The federal Centers for Medicare & Medicaid Services within the
U.S. Department of Health and Human Services is responsible for administering the Medicaid
program at the federal level. Florida Medicaid is the health care safety net for low-income
Floridians and is financed through state and federal funds.
4
Statewide Medicaid Managed Care
Approximately 72.5 percent of Florida Medicaid recipients
5
receive services through a managed
care plan contracted with the AHCA under the Statewide Medicaid Managed Care (SMMC)
program.
6
The SMMC program has three components: Managed Medical Assistance (MMA),
Long-Term Care (LTC), and the Prepaid Dental Health program.
7
Among these three
components, Florida’s SMMC program offers a health care package covering acute, preventive,
behavioral health, prescribed drugs, long-term care, and dental services. Florida’s SMMC
program benefits are authorized through federal waivers and are specifically required by the
Florida Legislature in ss. 409.973 and 409.98, F.S.
8
The AHCA awarded contracts to the current SMMC managed care plans through a competitive
procurement process called an Invitation to Negotiate (ITN). The AHCA awarded and executed
new contracts for SMMC 3.0 in October 2024 and officially rolled out the new SMMC 3.0
program on February 1, 2025.
9
The rate year for the SMMC contracts is October 1 through
September 30 of each contract year.
10
Managed care plans providing MMA program services are required to cover acute, preventive,
and other health care services, such as:
11
• Hospital services;
• Physician services;
• Pharmacy services;
• Behavioral health services;
3
Medicaid.gov, Medicaid, available at https://www.medicaid.gov/medicaid (last visited Mar. 27, 2025).
4
Section 20.42, F.S.
5
The other 27.5 percent of recipients receive Medicaid services through the fee-for-service (FFS) delivery model, where
providers contract directly with the AHCA to render services, billing and receiving reimbursement directly from the AHCA;
Florida Agency for Health Care Administration, Senate Bill 306 (Feb. 7, 2025) (on file with Senate Committee on Health
Policy).
6
Florida Agency for Health Care Administration, Florida Statewide Medicaid Enrollment Report As of February 28, 2025
(including Medikids Population), available at https://ahca.myflorida.com/content/download/26230/file/ENR_202502.xls (last
visited Mar. 27, 2025).
7
Florida Agency for Health Care Administration, Statewide Medicaid Managed Care, available at
https://ahca.myflorida.com/medicaid/statewide-medicaid-managed-care (last visited Mar. 27, 2025).
8
Florida Agency for Health Care Administration, Senate Bill 306 (Feb. 7, 2025) (on file with Senate Committee on Health
Policy).
9
Id.
10
Florida Agency for Health Care Administration, Senate Bill 1060 (Feb. 28, 2025) (on file with Senate Committee on
Health Policy).
11
Supra note 8. BILL: CS/SB 306 Page 3
• Transportation to medical services;
• Nursing facility services; and
• Other service benefits, including, but not limited to, medical equipment and supplies,
therapies, and home health services.
The AHCA contracts with LTC plans in each region to provide LTC services, including all home
and community-based waiver services, through their provider networks. Currently, all of the
LTC plans contracted with the AHCA are also contracted to provide MMA services,
streamlining care with a more comprehensive enrollment approach where a Medicaid recipient
can enroll with one plan for all services.
12
The SMMC program includes the following regions:
13
• Region A, which consists of Bay, Calhoun, Escambia, Franklin, Gadsden, Gulf, Holmes,
Jackson, Jefferson, Leon, Liberty, Madison, Okaloosa, Santa Rosa, Taylor, Wakulla, Walton,
and Washington counties.
• Region B, which consists of Alachua, Baker, Bradford, Citrus, Clay, Columbia, Dixie,
Duval, Flagler, Gilchrist, Hamilton, Hernando, Lafayette, Lake, Levy, Marion, Nassau,
Putnam, St. Johns, Sumter, Suwannee, Union, and Volusia counties.
• Region C, which consists of Pasco and Pinellas counties.
• Region D, which consists of Hardee, Highlands, Hillsborough, Manatee, and Polk counties.
• Region E, which consists of Brevard, Orange, Osceola, and Seminole counties.
• Region F, which consists of Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota
counties.
• Region G, which consists of Indian River, Martin, Okeechobee, Palm Beach, and St. Lucie
counties.
• Region H, which consists of Broward County.
• Region I, which consists of Miami-Dade and Monroe counties.
Provider Networks
A provider network is a list of doctors, hospitals, and other health care providers that a plan
contracts with to provide medical care to its enrollees. These providers are commonly known as
participating providers, and a provider that is not contracted with the plan is called a
nonparticipating provider.
14
SMMC Plan Accountability – Network Access & Adequacy
The SMMC plans must adhere to all requirements as specified in their contract with the AHCA,
including requirements to enter into provider agreements with a sufficient number of providers to
deliver all covered services to enrollees and ensure that each medically necessary covered
service is accessible and provided with reasonable promptness, including the utilization of
12
Id.
13
Section 409.966(2), F.S.
14
U.S. Department of Health & Human Services, Health Insurance Marketplace, What You Should Know About Provider
Networks, available at https://www.cms.gov/marketplace/outreach-and-education/what-you-should-know-provider-
networks.pdf (last visited Mar. 27, 2025). BILL: CS/SB 306 Page 4
nonparticipating providers.
15
If the managed care plan declines to include individual or group
providers in its provider network, the plan is required to give written notice to the affected
provider(s) of the reason for its decision.
16,17
Prior to implementation of SMMC 3.0 on February 1, 2025, the AHCA indicated that the
network sufficiency of each plan was assessed to ensure an adequate number of available
providers exists within the plans’ provider networks. Managed care plans are contractually
required to develop a printed and online (electronic) provider network directory to assist
enrollees in selecting from qualified providers. The plans must update their online provider
database at least weekly and provide printed copies of provider directories to enrollees upon
request, at no charge. The plans must have procedures to inform current enrollees and potential
enrollees, upon request, of any changes to service delivery and/or provider network.
On a regional basis, managed care plans must notify the AHCA within seven business days of a
decrease in the total number of primary care providers by more than five percent. Moreover, the
plans are required to submit an Annual Network Development Plan
18
that includes a description
or explanation of the current status of their network for each service covered.
19
Additionally, the plans are required to submit weekly Provider Network Verification (PNV)
files,
20
which include information on each plan’s provider network. The AHCA monitors the
PNV files to ensure contractually required provider network standards are being met. If a plan is
not compliant with these standards, the AHCA has actions available through its contracts that
can be applied, including liquidated damages.
21
Managed care plans online and printed provider
directories are monitored monthly for accuracy and completeness. Furthermore, the AHCA
monitors the networks to ensure that contractual provider-specific geographic access (time and
distance) standards for enrollees in urban or rural counties are maintained.
22
15
42 C.F.R. § 438.206(b)(4)
16
42 C.F.R. § 438.12(a)(1)
17
Supra note 8.
18
Florida Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Attachment II – Core Contract
Provisions (Feb. 2025), Page 236 of 267, available at
https://ahca.myflorida.com/content/download/26116/file/Attachment%20II%20-%20Core%20Contract%20Provisions.pdf
(last visited Mar. 27, 2025).
19
Supra note 8.
20
Florida Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Attachment II – Core Contract
Provisions (Feb. 2025), Page 234 of 267, available at
https://ahca.myflorida.com/content/download/26116/file/Attachment%20II%20-%20Core%20Contract%20Provisions.pdf
(last visited Mar. 27, 2025).
21
Florida Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Attachment II – Core Contract
Provisions (Feb. 2025), Page 201 of 267, available at
https://ahca.myflorida.com/content/download/26116/file/Attachment%20II%20-%20Core%20Contract%20Provisions.pdf
(last visited Mar. 27, 2025).
22
Supra note 8. BILL: CS/SB 306 Page 5
The required regional provider ratios and network adequacy standards, as well as the time and
distance standards for covered services, providers, and facilities, are contained within the
contracts between the AHCA and the Medicaid managed care plans.
23,24,25
Currently, at least 50 percent of primary care providers participating in a plan provider network
in regions A, B, E, G, H, and I must offer after hours
26
appointment availability to Medicaid
enrollees; however, regions C and D require at least 45 percent, and region F requires at least 40
percent.
27
III. Effect of Proposed Changes:
The bill amends s. 409.967, F.S., to require the AHCA to establish specific standards to ensure
enrollees have access to network providers during state holidays and outside regular business
hours. At least 50 percent of primary care providers participating in a plan provider network
must offer appointment availability to Medicaid enrollees outside regular business hours.
The bill defines the term “outside regular business hours” to mean Monday through Friday
between 5 p.m., and 8 a.m., local time and all-day Saturday and Sunday.
The bill provides an effective date of July 1, 2025.
23
Florida Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Exhibit II-A – Managed Medical
Assistance Program (Feb. 2025), Pages 55-58, 60-61, available at
https://ahca.myflorida.com/content/download/26117/file/Exhibit%20II-A%20-
%20Managed%20Medical%20Assistance%20%28MMA%29%20Program.pdf (last visited Mar. 27, 2025).
24
Florida Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Exhibit II-A – Managed Medical
Assistance Program (Feb. 2025), Pages 70-72, available at
https://ahca.myflorida.com/content/download/26117/file/Exhibit%20II-A%20-
%20Managed%20Medical%20Assistance%20%28MMA%29%20Program.pdf (last visited Mar. 27, 2025).
25
Florida Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Exhibit II-B – Long-Term Care
(LTC) Program (Feb. 2025), Pages 32-34, available at
https://ahca.myflorida.com/content/download/26117/file/Exhibit%20II-A%20-
%20Managed%20Medical%20Assistance%20%28MMA%29%20Program.pdf (last visited Mar. 27, 2025).
26
The AHCA defines “after hours” in its health plan contracts to mean the hours between 5:00 p.m., and 8:00 a.m., local
time, Monday through Friday inclusive, and all-day Saturday and Sunday. State holidays are also included. See Florida
Agency for Health Care Administration, 2025-2030 Model Health Plan Contract Attachment II – Core Contract Provisions
(Feb. 2025), Page 238, available at https://ahca.myflorida.com/content/download/26116/file/Attachment%20II%20-
%20Core%20Contract%20Provisions.pdf (last visited Apr. 2, 2025).
27
Supra note 24. BILL: CS/SB 306 Page 6
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:
None.
C. Government Sector Impact:
None.
VI. Technical Deficiencies:
None.
VII. Related Issues:
None.
VIII. Statutes Affected:
This bill substantially amends section 409.967 of the Florida Statutes. BILL: CS/SB 306 Page 7
IX. Additional Information:
A. Committee Substitute – Statement of Substantial Changes:
(Summarizing differences between the Committee Substitute and the prior version of the bill.)
CS by Health Policy on April 1, 2025:
The committee substitute:
• Removes the underlying bill’s amendments to Medicaid managed care plan
accountability statutes.
• Requires the AHCA to establish standards to ensure Medicaid enrollees have access
to network providers during state holidays and outside regular business hours.
• Requires Medicaid managed care plans to ensure at least 50 percent of primary care
providers participating in their network offer appointment availability to Medicaid
enrollees outside regular business hours.
• Defines the term “outside regular business hours” to mean Monday through Friday
between 5 p.m., and 8 a.m., local time and all-day Saturday and Sunday.
B. Amendments:
None.
This Senate Bill Analysis does not reflect the intent or official position of the bill’s introducer or the Florida Senate.