THE BILL ITSELF
HB 1097
Health Insurer Accountability
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A bill to be entitled
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An act relating to health insurer accountability;
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amending s. 408.7057, F.S.; requiring a health plan to
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participate in a filed claim dispute; providing
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penalties for failure to respond to a claim; requiring
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the Agency for Health Care Administration to notify a
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certain entity within a specified timeframe when a
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health plan fails to pay a provider under certain
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circumstances; requiring a health plan to pay a
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provider within a specified timeframe after the
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agency's order; providing penalties; amending s.
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409.967, F.S.; providing credentialing requirements
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for a managed care plan; requiring each managed care
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plan to identify to the agency and the Office of
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Insurance Regulation any ownership interest or
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affiliation of any kind with certain entities;
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providing requirements for the identification of such
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information; requiring each managed care plan to
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report specified information to the agency and the
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office in writing within a specified timeframe;
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removing a provision requiring the results of certain
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audit reports to be dispositive; amending s. 409.975,
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F.S.; requiring managed care contracts to include
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provider notifications regarding certain denials of
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coverage; amending ss. 627.6131 and 641.315, F.S.;
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prohibiting an insurer from denying certain claims
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under certain circumstances; providing notification
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requirements and penalties; amending ss. 409.973 and
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409.9855, F.S.; conforming cross-references; providing
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an effective date.
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Be It Enacted by the Legislature of the State of Florida:
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Section 1. Subsection (7) of section 408.7057, Florida
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Statutes, is renumbered as subsection (8), subsection (5) is
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amended, paragraph (i) is added to subsection (2), and a new
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subsection (7) is added to that section, to read:
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408.7057 Statewide provider and health plan claim dispute
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resolution program.—
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(2)
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(i) A health plan must participate in a filed claim
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dispute. Failure to respond as provided in paragraph (f) shall
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result in a default against the health plan.
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(5) The agency shall notify within 7 days the appropriate
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licensure or certification entity whenever there is:
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(a) A failure to pay as provided in subsection (7); or
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(b) A violation of a final order issued by the agency
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pursuant to this section.
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(7) A health plan that does not prevail in the agency's
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order shall pay the provider the amount provided in the order
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within 35 days after the order is entered. A health plan that
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does not pay the required amount within the required timeframe
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is subject to a penalty of up to $500 per day until the amount
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is paid. Section 2. Subsections (3) and (4) of section 409.967,
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Florida Statutes, are renumbered as subsections (4) and (5),
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respectively, paragraph (e) of present subsection (3) is
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amended, paragraphs (p) and (q) are added to subsection (2), and
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a new subsection (3) is added to that section, to read:
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409.967 Managed care plan accountability.—
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(2) The agency shall establish such contract requirements
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as are necessary for the operation of the statewide managed care
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program. In addition to any other provisions the agency may deem
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necessary, the contract must require:
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(p) Credentialing.—
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1. A managed care plan shall determine whether it will
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contract with a provider within 30 calendar days after receipt
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of the verified credentialing information from a credentialing
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verification organization either designated by the agency or
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contracted by managed care organizations as part of a
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credentialing alliance. Within 15 days after a contract is
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executed, a managed care plan shall ensure that any internal
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processing systems of the managed care plan have been updated to
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include:
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a. The accepted provider contract.
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b. The provider as a participating provider.
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2. For the purpose of reimbursement of claims, once a
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provider has met the terms and conditions for credentialing and
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enrollment, the provider's credentialing application date shall
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be the date from which the provider's claims become eligible for
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payment.
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3. A managed care plan may not require a provider to
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appeal or resubmit any clean claim submitted during the time
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period between the provider's credentialing application date and
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the completion of the credentialing process.
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(q) Ownership interest or affiliation.—
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1. Each managed care plan shall identify to the agency and
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the Office of Insurance Regulation any ownership interest or
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affiliation of any kind with any provider, provider group, or
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company responsible for providing any pharmacy, diagnostics,
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care coordination, care delivery, direct health care services,
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administrative services, or financial services.
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2. Each managed care plan shall also identify to the
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agency and the Office of Insurance Regulation any ownership
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affiliation of any kind with any entity which, either directly
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or indirectly, through one or more intermediaries:
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a. Has an investment or ownership interest of any kind
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with any entity providing pharmacy, diagnostics, care
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coordination, care delivery, direct health care services, or
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administrative services;
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b. Shares common ownership with any entity providing
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pharmacy, diagnostics, care coordination, care delivery, direct
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health care services, or administrative services; or
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c. Has an investor or a holder of an ownership interest of
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any kind with any entity providing pharmacy, diagnostics, care
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coordination, care delivery, direct health care services, or
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administrative services.
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(3) Each managed care plan shall report any change in
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information in subsection (2) to the agency and the Office of
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Insurance Regulation in writing within 60 days after the change
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occurs.
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(4)(3) ACHIEVED SAVINGS REBATE.—
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(e) Once the certified public accountant completes the
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audit, the certified public accountant shall submit an audit
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report to the agency attesting to the achieved savings of the
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plan. The agency shall review the report to determine compliance
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with the requirements of this subsection. The agency shall
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notify the certified public accountant of any deficiencies in
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the audit report. The certified public accountant must correct
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such deficiencies in the audit report and resubmit the revised
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audit report to the agency before the report is considered
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final. Once finalized, the results of the audit report are
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dispositive.
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Section 3. Subsection (7) is added to section 409.975,
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Florida Statutes, to read:
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409.975 Managed care plan accountability.—In addition to
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the requirements of s. 409.967, plans and providers
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participating in the managed medical assistance program shall
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comply with the requirements of this section.
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(7) PROVIDER NOTIFICATION REQUIREMENT.—Each managed care
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contract with a provider must include provider notifications
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regarding denials of coverage in accordance with ss.
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627.6131(22) and 641.315(15).
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Section 4. Subsection (22) is added to section 627.6131,
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Florida Statutes, to read:
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627.6131 Payment of claims.—
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(22) For circumstances in subparagraph (21)(a)1. and sub-
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subparagraphs (21)(a)5.d. and e., an insurer may not deny a
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claim of a previously authorized health care service unless the
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insurer has notified both the insured and the treating provider
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of the insured's change in coverage status or applicable benefit
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limitation. Notification to the provider must be issued
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contemporaneously with the notice required to be given to the
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insured under this section. Failure to provide such notification
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shall preclude the insurer from denying payment for the
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authorized service.
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Section 5. Subsection (15) is added to section 641.315,
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Florida Statutes, to read:
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641.315 Provider contracts.—
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(15) For circumstances in subparagraph (14)(a)1. and sub-
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subparagraphs (14)(a)5.d. and e., an insurer may not deny a
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claim of a previously authorized health care service unless the
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insurer has notified both the insured and the treating provider
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of the insured's change in coverage status or applicable benefit
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limitation. Notification to the provider must be issued
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contemporaneously with the notice required to be given to the
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insured under this section. Failure to provide such notification
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shall preclude the insurer from denying payment for the
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authorized service.
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Section 6. Paragraph (b) of subsection (5) of section
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409.973, Florida Statutes, is amended to read:
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409.973 Benefits.—
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(5) PROVISION OF DENTAL SERVICES.—
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(b) In the event the Legislature takes no action before
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July 1, 2017, with respect to the report findings required under
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paragraph (a), the agency shall implement a statewide Medicaid
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prepaid dental health program for children and adults with a
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choice of at least two licensed dental managed care providers
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who must have substantial experience in providing dental care to
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Medicaid enrollees and children eligible for medical assistance
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under Title XXI of the Social Security Act and who meet all
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agency standards and requirements. To qualify as a provider
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under the prepaid dental health program, the entity must be
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licensed as a prepaid limited health service organization under
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part I of chapter 636 or as a health maintenance organization
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under part I of chapter 641. The contracts for program providers
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shall be awarded through a competitive procurement process.
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Beginning with the contract procurement process initiated during
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the 2023 calendar year, the contracts must be for 6 years and
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may not be renewed; however, the agency may extend the term of a
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plan contract to cover delays during a transition to a new plan
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provider. The agency shall include in the contracts a medical
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loss ratio provision consistent with s. 409.967(5) s.
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409.967(4). The agency is authorized to seek any necessary state
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plan amendment or federal waiver to commence enrollment in the
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Medicaid prepaid dental health program no later than March 1,
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2019. The agency shall extend until December 31, 2024, the term
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of existing plan contracts awarded pursuant to the invitation to
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negotiate published in October 2017. Section 7. Paragraph (c) of subsection (5) of section
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409.9855, Florida Statutes, is amended to read:
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409.9855 Pilot program for individuals with developmental
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disabilities.—
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(5) PAYMENT.—
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(c) The revenues and expenditures of the selected plan
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which are associated with the implementation of the pilot
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program must be included in the reporting and regulatory
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requirements established in s. 409.967(4) s. 409.967(3).
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Section 8. This act shall take effect July 1, 2026.