HB 1453 full text · Session Watch

1 A bill to be entitled

2 An act relating to the state Medicaid program;

3 amending s. 409.904, F.S.; authorizing the Agency for

4 Health Care Administration to conduct retrospective

5 reviews and audits of certain claims under the state

6 Medicaid program for a specified purpose; creating s.

7 409.9041, F.S.; providing legislative findings;

8 requiring the agency, in coordination with the

9 Department of Children and Families, to implement

10 mandatory work and community engagement requirements

11 for able-bodied adults as a condition of obtaining and

12 maintaining Medicaid coverage; requiring the agency to

13 seek federal approval to implement such requirements

14 for certain populations; specifying populations that

15 are subject to such work and community engagement

16 requirements; providing exceptions; defining the term

17 "family caregiver"; specifying the types of activities

18 which may satisfy the work and community engagement

19 requirements; providing that a certain population is

20 required to engage in work or community engagement

21 activities only during standard school hours;

22 requiring persons eligible for Medicaid to demonstrate

23 compliance with the work and community engagement

24 requirements at specified times as a condition of

25 maintaining Medicaid coverage; requiring the agency to

26 develop a process for ensuring compliance with the

27 work and community engagement requirements; requiring

28 that such process align, to the extent possible, with

29 certain existing processes; requiring the department

30 to verify compliance with the work and community

31 engagement requirements at specified intervals;

32 requiring the agency, in coordination with the

33 department, to conduct outreach regarding

34 implementation of the work and community engagement

35 requirements; specifying requirements for such

36 outreach; specifying procedures in the event of

37 noncompliance; requiring the agency, in coordination

38 with the department, to notify a Medicaid recipient of

39 a finding of noncompliance and the impact to

40 eligibility for continued receipt of services;

41 specifying requirements for such notice; amending s.

42 409.905, F.S.; requiring the agency to maintain cost-

43 effective purchasing practices in its coverage of

44 hospital inpatient services rendered to Medicaid

45 recipients; amending 409.906, F.S.; requiring the

46 agency to seek federal approval to implement a program

47 for expanded coverage of home- and community-based

48 behavioral health services for a specified population;

49 specifying the goal of the program; requiring the

50 agency to work in coordination with the department to

51 develop and implement the program upon federal

52 approval; amending s. 409.91195, F.S.; revising the

53 purpose of the Medicaid Pharmaceutical and

54 Therapeutics Committee to include creation of a

55 Medicaid preferred physician-administered drug list, a

56 Medicaid preferred product list, and a high-cost drug

57 list; requiring the agency to adopt such lists upon

58 recommendation of the committee; specifying the

59 frequency with which the committee must review such

60 lists for any recommended additions or deletions;

61 specifying parameters for such recommended additions

62 and deletions; providing that reimbursement for drugs

63 not included on such lists is subject to prior

64 authorization, with an exception; requiring the agency

65 to publish and disseminate such lists to all Medicaid

66 providers in the state by posting on the agency's

67 website or in other media; providing requirements for

68 public testimony related to proposed inclusions on or

69 exclusions from certain lists; requiring the committee

70 to consider certain factors when developing such

71 recommended additions and deletions; amending s.

72 409.912, F.S.; revising the components of the Medicaid

73 prescribed-drug spending-control program to include

74 the preferred physician-administered drug list, the

75 preferred product list, and the high-cost drug list;

76 providing requirements for such lists; providing that

77 the agency does not need to follow rulemaking

78 procedures of ch. 120, F.S., when posting updates to

79 such lists; establishing an alternative reimbursement

80 methodology for long-acting injectables administered

81 in a hospital facility setting for severe mental

82 illness; requiring the agency to contract with a

83 vendor to perform a fiscal impact study of the federal

84 340B Drug Pricing Program; providing requirements for

85 the study; requiring specified entities to submit

86 certain data to the agency for purposes of the study;

87 providing that noncompliance with such requirement may

88 result in sanctions from the agency or the Board of

89 Pharmacy, as applicable; requiring the agency to

90 submit the results of the study to the Governor and

91 the Legislature by a specified date; providing

92 construction; amending s. 409.9122, F.S.; revising

93 requirements for managed care plan encounter data

94 submission and analysis under the Medicaid Encounter

95 Data System; amending s. 409.913, F.S.; revising the

96 definition of the term "overpayment"; providing that

97 determinations of an overpayment under the Medicaid

98 program may be based upon retrospective reviews,

99 investigations, analyses, or audits conducted by the

100 agency to determine possible fraud, abuse,

101 overpayment, or recipient neglect; providing that

102 certain notices may be provided using other common

103 carriers, as well as through the United States Postal

104 Service; amending s. 409.962, F.S.; defining the term

105 "affiliate"; amending s. 409.967, F.S.; requiring that

106 managed care plan contracts require any third-party

107 administrative entity contracted with the plan to

108 adhere to specified requirements; specifying

109 additional types of payments which may not be included

110 in calculating income for purposes of the achieved

111 savings rebate; requiring the agency to ensure

112 oversight of affiliated entities and related parties

113 within the Statewide Medicaid Managed Care program;

114 requiring the agency to examine specified records and

115 data related to such entities and parties; requiring

116 the agency to consider certain data and findings when

117 determining its final medical loss ratio and during

118 the rate setting process under the program; creating

119 s. 409.9675, F.S.; defining the term "control";

120 requiring managed care plans to report to the agency

121 and the Office of Insurance Regulation the existence

122 of and details relating to certain affiliations by a

123 specified date and annually thereafter; requiring

124 managed care plans to report any change in such

125 information to the agency and the office in writing

126 within a specified timeframe; requiring the agency to

127 calculate, analyze, and publicly report on the

128 agency's website an assessment of affiliated entity

129 payment transactions in the Medicaid program and

130 certain administrative costs by a specified date and

131 annually thereafter; providing requirements for the

132 assessment; amending s. 409.973, F.S.; requiring the

133 agency to implement an Integrated Managed Care Pilot

134 Program in designated regions by a specified date;

135 requiring the agency to submit a request for federal

136 approval for the program by a specified date;

137 requiring the agency to implement the program in

138 specified regions by a specified date, contingent on

139 federal approval; providing requirements for

140 implementing the program, including requirements for

141 plan contracts, service delivery, and provider

142 credentialing; providing for the termination of plan

143 contracts under certain circumstances; requiring the

144 agency to establish measures for evaluating the

145 program; requiring the agency to contract with an

146 independent evaluator to conduct the evaluations;

147 specifying requirements for the evaluations; requiring

148 the agency to submit a report on the performance of

149 the pilot program to the Governor and the Legislature

150 beginning on a specified date and annually thereafter;

151 amending ss. 409.91196 and 627.42392, F.S.; conforming

152 cross-references; providing an effective date.

154 Be It Enacted by the Legislature of the State of Florida:

156 Section 1. Subsection (4) of section 409.904, Florida

157 Statutes, is amended to read:

158 409.904 Optional payments for eligible persons.—The agency

159 may make payments for medical assistance and related services on

160 behalf of the following persons who are determined to be

161 eligible subject to the income, assets, and categorical

162 eligibility tests set forth in federal and state law. Payment on

163 behalf of these Medicaid eligible persons is subject to the

164 availability of moneys and any limitations established by the

165 General Appropriations Act or chapter 216.

166 (4) A low-income person who meets all other requirements

167 for Medicaid eligibility except citizenship and who is in need

168 of emergency medical services. The eligibility of such a

169 recipient is limited to the period of the emergency, in

170 accordance with federal regulations. The agency may conduct

171 retrospective reviews or audits of services rendered to the

172 individual and claims submitted by the provider to validate the

173 existence and duration of the emergency medical condition and

174 whether the services rendered were necessary to treat the

175 emergency medical condition regardless of whether the provider

176 obtained prior authorization for the services.

177 Section 2. Section 409.9041, Florida Statutes, is created

178 to read:

179 409.9041 Medicaid work and community engagement

180 requirements.—

181 (1)(a) The Legislature finds that assisting able-bodied

182 adult Medicaid recipients in achieving self-sufficiency through

183 meaningful work and community engagement is essential to

184 ensuring that the state Medicaid program remains a sustainable

185 resource for residents who are most in need of such assistance.

186 (b) The agency, in coordination with the department, shall

187 implement mandatory work and community engagement requirements

188 for able-bodied adults as a condition of obtaining and

189 maintaining coverage under the state Medicaid program.

190 (2) The agency shall seek federal approval to implement

191 mandatory work and community engagement requirements for certain

192 populations, as specified in this section, as a condition of

193 obtaining and maintaining coverage under the state Medicaid

194 program.

195 (3)(a) Medicaid recipients between the ages of 18 and 64

196 years must meet the work or community engagement requirements of

197 this section, unless they are one of the following:

198 1. Indian as defined under 42 C.F.R. s. 438.14(a).

199 2. A parent, guardian, caretaker relative, or family

200 caregiver of a dependent child younger than 6 years of age or of

201 a disabled individual. For purposes of this paragraph, the term

202 "family caregiver" means an adult family member or other

203 individual who has a significant relationship with, and who

204 provides a broad range of assistance to, an individual with a

205 chronic or other health condition, disability, or functional

206 limitation.

207 3. Former foster youth younger than 23 years of age.

208 4. A veteran with a total disability, as specified under

209 38 C.F.R. s. 3.340 or as specified by a Veteran Affairs

210 Disability Ratings Letter issued by the United States Department

211 of Veterans Affairs.

212 5. An individual classified as medically frail under the

213 Medicaid Institutionalized Care Program; categorized as aged,

214 blind, or disabled under the state Medicaid program; or who has

215 a developmental disability as defined in s. 393.063.

216 6. An individual living in a household that receives

217 Supplemental Nutrition Assistance Program benefits and who is

218 already in compliance with work requirements pursuant to s.

219 445.024.

220 7. An individual participating in a residential substance

221 use disorder treatment program.

222 8. An inmate of a public institution.

223 9. A woman eligible for Medicaid coverage in a pregnancy-

224 related or postpartum care category.

225 (b) A person may satisfy the work or community engagement

226 requirements of this section by participating in one or more of

227 the following activities for at least 80 hours per month:

228 1. Paid employment.

229 2. On-the-job-training.

230 3. Vocational educational training.

231 4. Job skills training directly related to employment.

232 5. Education directly related to employment.

233 6. Satisfactory attendance at a secondary school or in a

234 course of study leading to a high school equivalency diploma.

235 7. Enrollment at least half-time as defined in 34 C.F.R.

236 s. 668.2(b) in a postsecondary education program to obtain a

237 credential on the Master Credentials List as maintained pursuant

238 to s. 445.004(6)(e).

239 8. Any other work activity designated as such by the

240 Department of Commerce and provided by a local workforce

241 development board pursuant to s. 445.024.

242 (c) Parents with children ages 6 through 18 are required

243 to engage in work or community engagement activities only during

244 standard school hours.

245 (4)(a) Notwithstanding any other statutory provision, in

246 order to maintain Medicaid coverage, an eligible Medicaid

247 recipient must, before enrollment and upon any redetermination

248 for coverage, demonstrate compliance with the work or community

249 engagement requirements of this section.

250 (b) The agency shall develop a process for ensuring

251 compliance with this section which aligns, to the extent

252 possible, with the processes currently in place relating to work

253 and community engagement requirements authorized under the

254 state's Supplemental Nutrition Assistance Program, including,

255 but not limited to, participant registration with a local

256 CareerSource center, employment and training programs, and

257 collaboration with the state's local workforce boards.

258 (c) The department shall verify, in accordance with its

259 procedures, that an individual subject to the work and community

260 engagement requirements of this section demonstrates compliance

261 during the individual's regularly scheduled redetermination of

262 eligibility, or more frequently as determined by the department.

263 (5) The agency, in coordination with the department, shall

264 conduct outreach regarding the implementation of the work and

265 community engagement requirements of this section. The outreach

266 much include, at a minimum, notification to impacted

267 individuals, including timelines for implementation,

268 requirements for compliance, penalties for noncompliance, and

269 information on how to request an exemption.

270 (6) If a recipient subject to the work and community

271 engagement requirements of this section is determined to be in

272 noncompliance with such requirements, the agency, in

273 coordination with the department, must notify the recipient of

274 the finding of noncompliance and the impact to his or her

275 eligibility for continued receipt of Medicaid services. The

276 notice must include, at a minimum, notification of all of the

277 following:

278 (a) That the recipient is eligible for a grace period of

279 30 days to either come into compliance with the requirements or

280 request an exemption from the requirements and that Medicaid

281 coverage of services will continue during the grace period.

282 (b) That if, following the 30-day period, the individual

283 has not come into compliance with or requested an exemption from

284 the work and community engagement requirements, his or her

285 application for assistance will be denied and services

286 terminated at the end of the month following the month in which

287 such 30-calendar-day period ends.

288 (c) The right of the individual to request a fair hearing

289 if he or she is determined to be noncompliant with program

290 requirements and disenrolled from the state Medicaid program.

291 (d) How he or she can reapply for medical assistance under

292 the state Medicaid program.

293 Section 3. Paragraph (f) is added to subsection (5) of

294 section 409.905, Florida Statutes, to read:

295 409.905 Mandatory Medicaid services.—The agency may make

296 payments for the following services, which are required of the

297 state by Title XIX of the Social Security Act, furnished by

298 Medicaid providers to recipients who are determined to be

299 eligible on the dates on which the services were provided. Any

300 service under this section shall be provided only when medically

301 necessary and in accordance with state and federal law.

302 Mandatory services rendered by providers in mobile units to

303 Medicaid recipients may be restricted by the agency. Nothing in

304 this section shall be construed to prevent or limit the agency

305 from adjusting fees, reimbursement rates, lengths of stay,

306 number of visits, number of services, or any other adjustments

307 necessary to comply with the availability of moneys and any

308 limitations or directions provided for in the General

309 Appropriations Act or chapter 216.

310 (5) HOSPITAL INPATIENT SERVICES.—The agency shall pay for

311 all covered services provided for the medical care and treatment

312 of a recipient who is admitted as an inpatient by a licensed

313 physician or dentist to a hospital licensed under part I of

314 chapter 395. However, the agency shall limit the payment for

315 inpatient hospital services for a Medicaid recipient 21 years of

316 age or older to 45 days or the number of days necessary to

317 comply with the General Appropriations Act.

318 (f) In its coverage of services under this subsection, the

319 agency shall maintain cost-effective purchasing practices as

320 required by s. 409.912.

321 Section 4. Present subsections (14) through (29) of

322 section 409.906, Florida Statutes, are redesignated as

323 subsections (15) through (30), respectively, and a new

324 subsection (14) is added to that section, to read:

325 409.906 Optional Medicaid services.—Subject to specific

326 appropriations, the agency may make payments for services which

327 are optional to the state under Title XIX of the Social Security

328 Act and are furnished by Medicaid providers to recipients who

329 are determined to be eligible on the dates on which the services

330 were provided. Any optional service that is provided shall be

331 provided only when medically necessary and in accordance with

332 state and federal law. Optional services rendered by providers

333 in mobile units to Medicaid recipients may be restricted or

334 prohibited by the agency. Nothing in this section shall be

335 construed to prevent or limit the agency from adjusting fees,

336 reimbursement rates, lengths of stay, number of visits, or

337 number of services, or making any other adjustments necessary to

338 comply with the availability of moneys and any limitations or

339 directions provided for in the General Appropriations Act or

340 chapter 216. If necessary to safeguard the state's systems of

341 providing services to elderly and disabled persons and subject

342 to the notice and review provisions of s. 216.177, the Governor

343 may direct the Agency for Health Care Administration to amend

344 the Medicaid state plan to delete the optional Medicaid service

345 known as "Intermediate Care Facilities for the Developmentally

346 Disabled." Optional services may include:

347 (14) HOME- AND COMMUNITY-BASED BEHAVIORAL HEALTH

348 SERVICES.—The agency shall seek federal approval to implement a

349 program that covers an expanded array of home- and community-

350 based services for adults 18 years of age and older diagnosed

351 with a serious mental illness who are high utilizers of

352 behavioral health services in an institutional setting. The

353 program must be designed to reduce the need for institutional

354 levels of care for adults with a serious mental illness. The

355 agency shall work in coordination with the Department of

356 Children and Families to develop and implement the program upon

357 receiving federal approval.

358 Section 5. Section 409.91195, Florida Statutes, is amended

359 to read:

360 409.91195 Medicaid Pharmaceutical and Therapeutics

361 Committee.—There is created a Medicaid Pharmaceutical and

362 Therapeutics Committee within the agency for the purpose of

363 developing a Medicaid preferred drug list, a Medicaid preferred

364 physician-administered drug list, a Medicaid preferred product

365 list, and a high-cost drug list.

366 (1) The committee shall be composed of 11 members

367 appointed by the Governor. Four members shall be physicians,

368 licensed under chapter 458; one member licensed under chapter

369 459; five members shall be pharmacists licensed under chapter

370 465; and one member shall be a consumer representative. The

371 members shall be appointed to serve for terms of 2 years from

372 the date of their appointment. Members may be appointed to more

373 than one term. The agency shall serve as staff for the committee

374 and assist them with all ministerial duties. The Governor shall

375 ensure that at least some of the members of the committee

376 represent Medicaid participating physicians and pharmacies

377 serving all segments and diversity of the Medicaid population,

378 and have experience in either developing or practicing under a

379 preferred drug list. At least one of the members shall represent

380 the interests of pharmaceutical manufacturers.

381 (2) Committee members shall select a chairperson and a

382 vice chairperson each year from the committee membership.

383 (3) The committee shall meet at least quarterly and may

384 meet at other times at the discretion of the chairperson and

385 members. The committee shall comply with rules adopted by the

386 agency, including notice of any meeting of the committee

387 pursuant to the requirements of the Administrative Procedure

388 Act.

389 (4) Upon recommendation of the committee, the agency shall

390 adopt a preferred drug list, a preferred physician-administered

391 drug list, a preferred product list, and a high-cost drug list

392 as described in s. 409.912(5). To the extent feasible, the

393 committee shall review all drug or product classes included on

394 the preferred drug list, the preferred physician-administered

395 drug list, and the preferred product list every 12 months, and

396 the high-cost drug list every 6 months. The committee may

397 recommend additions to and deletions from the lists ~~preferred~~

398 ~~drug list,~~ such that the lists provide ~~preferred drug list~~

399 ~~provides~~ for medically appropriate drug and product therapies

400 for Medicaid patients which achieve cost savings contained in

401 the General Appropriations Act.

402 (5) Except for antiretroviral drugs, reimbursement of

403 drugs not included on the preferred drug list, preferred

404 physician-administered drug list, preferred product list, or

405 high-cost drug list is subject to prior authorization.

406 (6) The agency shall publish and disseminate the preferred

407 drug list, preferred physician-administered drug list, preferred

408 product list, and high-cost drug list to all Medicaid providers

409 in the state by Internet posting on the agency's website or in

410 other media.

411 (7) The committee shall ensure that interested parties,

412 including pharmaceutical manufacturers agreeing to provide a

413 supplemental rebate as outlined in this chapter, have an

414 opportunity to present public testimony to the committee with

415 information or evidence supporting inclusion of a drug or

416 product on the preferred drug list, preferred physician-

417 administered drug list, or preferred product list. Such public

418 testimony shall occur before ~~prior to~~ any recommendations made

419 by the committee for inclusion or exclusion from the preferred

420 drug list, preferred physician-administered drug list, or

421 preferred product list. Upon timely notice, the agency shall

422 ensure that any drug that has been approved or had any of its

423 particular uses approved by the United States Food and Drug

424 Administration under a priority review classification will be

425 reviewed by the committee at the next regularly scheduled

426 meeting following 3 months of distribution of the drug to the

427 general public.

428 (8) The committee shall develop its preferred drug list,

429 preferred physician-administered drug list, preferred product

430 list, and high-cost drug list recommendations by considering the

431 clinical efficacy, safety, and cost-effectiveness of a product.

432 (9) The Medicaid Pharmaceutical and Therapeutics Committee

433 may also make recommendations to the agency regarding the prior

434 authorization of any prescribed drug covered by Medicaid.

435 (10) Medicaid recipients may appeal agency preferred drug

436 formulary decisions using the Medicaid fair hearing process

437 administered by the Agency for Health Care Administration.

438 Section 6. Paragraph (a) of subsection (5) of section

439 409.912, Florida Statutes, is amended, and subsection (14) is added to that section, to read:

441 409.912 Cost-effective purchasing of health care.—The

442 agency shall purchase goods and services for Medicaid recipients

443 in the most cost-effective manner consistent with the delivery

444 of quality medical care. To ensure that medical services are

445 effectively utilized, the agency may, in any case, require a

446 confirmation or second physician's opinion of the correct

447 diagnosis for purposes of authorizing future services under the

448 Medicaid program. This section does not restrict access to

449 emergency services or poststabilization care services as defined

450 in 42 C.F.R. s. 438.114. Such confirmation or second opinion

451 shall be rendered in a manner approved by the agency. The agency

452 shall maximize the use of prepaid per capita and prepaid

453 aggregate fixed-sum basis services when appropriate and other

454 alternative service delivery and reimbursement methodologies,

455 including competitive bidding pursuant to s. 287.057, designed

456 to facilitate the cost-effective purchase of a case-managed

457 continuum of care. The agency shall also require providers to

458 minimize the exposure of recipients to the need for acute

459 inpatient, custodial, and other institutional care and the

460 inappropriate or unnecessary use of high-cost services. The

461 agency shall contract with a vendor to monitor and evaluate the

462 clinical practice patterns of providers in order to identify

463 trends that are outside the normal practice patterns of a

464 provider's professional peers or the national guidelines of a

465 provider's professional association. The vendor must be able to

466 provide information and counseling to a provider whose practice

467 patterns are outside the norms, in consultation with the agency,

468 to improve patient care and reduce inappropriate utilization.

469 The agency may mandate prior authorization, drug therapy

470 management, or disease management participation for certain

471 populations of Medicaid beneficiaries, certain drug classes, or

472 particular drugs to prevent fraud, abuse, overuse, and possible

473 dangerous drug interactions. The Pharmaceutical and Therapeutics

474 Committee shall make recommendations to the agency on drugs for

475 which prior authorization is required. The agency shall inform

476 the Pharmaceutical and Therapeutics Committee of its decisions

477 regarding drugs subject to prior authorization. The agency is

478 authorized to limit the entities it contracts with or enrolls as

479 Medicaid providers by developing a provider network through

480 provider credentialing. The agency may competitively bid single-

481 source-provider contracts if procurement of goods or services

482 results in demonstrated cost savings to the state without

483 limiting access to care. The agency may limit its network based

484 on the assessment of beneficiary access to care, provider

485 availability, provider quality standards, time and distance

486 standards for access to care, the cultural competence of the

487 provider network, demographic characteristics of Medicaid

488 beneficiaries, practice and provider-to-beneficiary standards,

489 appointment wait times, beneficiary use of services, provider

490 turnover, provider profiling, provider licensure history,

491 previous program integrity investigations and findings, peer

492 review, provider Medicaid policy and billing compliance records,

493 clinical and medical record audits, and other factors. Providers

494 are not entitled to enrollment in the Medicaid provider network.

495 The agency shall determine instances in which allowing Medicaid

496 beneficiaries to purchase durable medical equipment and other

497 goods is less expensive to the Medicaid program than long-term

498 rental of the equipment or goods. The agency may establish rules

499 to facilitate purchases in lieu of long-term rentals in order to

500 protect against fraud and abuse in the Medicaid program as

501 defined in s. 409.913. The agency may seek federal waivers

502 necessary to administer these policies.

503 (5)(a) The agency shall implement a Medicaid prescribed-

504 drug spending-control program that includes the following

505 components:

506 1. A Medicaid preferred drug list and a Medicaid

507 physician-administered drug list. The preferred drug list, ~~which~~

508 shall be a listing of cost-effective therapeutic options

509 recommended by the Medicaid Pharmacy and Therapeutics Committee

510 established pursuant to s. 409.91195 and adopted by the agency

511 for each therapeutic class on the preferred drug list. At the

512 discretion of the committee, and when feasible, the preferred

513 drug list should include at least two products in a therapeutic

514 class. The physician-administered drug list shall be a listing

515 of physician-administered drugs covered by the state Medicaid

516 program, based on the United States Food and Drug

517 Administration's approved indications and compendia in 42 U.S.C.

518 s. 1396r-8(g)(1)(B). Within the preferred physician-administered

519 drug list, there must be a section containing a list of

520 preferred physician-administered drugs that are cost-effective

521 therapeutic options recommended by the Medicaid Pharmaceutical

522 and Therapeutics Committee established pursuant to s. 409.91195.

523 The physician-administered drug list must be updated at least

524 twice a year. The agency may post and update the preferred drug

525 list and the preferred physician-administered drug ~~updates to~~

526 ~~the~~ list on an Internet website without following the rulemaking

527 procedures of chapter 120. Antiretroviral agents are excluded

528 from the preferred drug list. The agency shall also limit the

529 amount of a prescribed drug dispensed to no more than a 34-day

530 supply unless the drug products' smallest marketed package is

531 greater than a 34-day supply, or the drug is determined by the

532 agency to be a maintenance drug in which case a 100-day maximum

533 supply may be authorized. The agency may seek any federal

534 waivers necessary to implement these cost-control programs and

535 to continue participation in the federal Medicaid rebate

536 program, or alternatively to negotiate state-only manufacturer

537 rebates. The agency may adopt rules to administer this

538 subparagraph. The agency shall continue to provide unlimited

539 contraceptive drugs and items. The agency must establish

540 procedures to ensure that:

541 a. There is a response to a request for prior

542 authorization by telephone or other telecommunication device

543 within 24 hours after receipt of a request for prior

544 authorization; and

545 b. A 72-hour supply of the drug prescribed is provided in

546 an emergency or when the agency does not provide a response

547 within 24 hours as required by sub-subparagraph a.

548 2. A Medicaid preferred product list, which shall be a

549 listing of cost-effective therapeutic supplies recommended by

550 the Medicaid Pharmaceutical and Therapeutics Committee

551 established pursuant to s. 409.91195 and adopted by the agency

552 for each product class listed on the preferred product list and

553 reimbursed by the state Medicaid program through the pharmacy

554 point-of-sale. The agency may post the preferred product list

555 and updates to the list on the agency's website without

556 following the rulemaking procedures of chapter 120.

557 3. A list of high-cost drugs recommended by the Medicaid

558 Pharmaceutical and Therapeutics Committee established pursuant

559 to s. 409.91195 and adopted by the agency, for the purpose of

560 coverage, reimbursement, or billing guidance. The agency may

561 post the high-cost drug list and updates to the list on an

562 Internet website without following the rulemaking procedures of

563 chapter 120.

564 4. A provider of prescribed drugs is reimbursed in an

565 amount not to exceed the lesser of the actual acquisition cost

566 based on the Centers for Medicare and Medicaid Services National

567 Average Drug Acquisition Cost pricing files plus a professional

568 dispensing fee, the wholesale acquisition cost plus a

569 professional dispensing fee, the state maximum allowable cost

570 plus a professional dispensing fee, or the usual and customary

571 charge billed by the provider.

572 5. A hospital facility administering long-acting

573 injectables for severe mental illness shall be reimbursed

574 separately from the diagnosis-related group. Long-acting

575 injectables administered for severe mental illness in a hospital

576 facility setting shall be reimbursed at no less than the actual

577 acquisition cost of the drug.

578 6. The agency shall contract with a vendor to perform a

579 detailed fiscal impact study to evaluate the 340B Drug Pricing

580 Program administered by the Health Resources and Services

581 Administration. The study must evaluate 340B compliance, 340B

582 drug purchases, and reimbursement methodologies within the fee-

583 for-service program and Statewide Medicaid Managed Care program.

584 Statewide Medicaid Managed Care plans, pharmacy benefit

585 managers, and Medicaid providers shall submit to the agency all

586 data necessary for the completion of the study, including, but

587 not limited to, information related to drug purchasing,

588 reimbursement, billing and coding, and dispensing. Noncompliance

589 with the 340B data submission requirements of this subparagraph

590 may result in sanctions from the agency or the Board of

591 Pharmacy, as applicable. The agency shall submit the results of

592 the study to the Governor, the President of the Senate, and the

593 Speaker of the House of Representatives by June 30, 2027.

594 7.3. The agency shall develop and implement a process for

595 managing the drug therapies of Medicaid recipients who are using

596 significant numbers of prescribed drugs each month. The

597 management process may include, but is not limited to,

598 comprehensive, physician-directed medical-record reviews, claims

599 analyses, and case evaluations to determine the medical

600 necessity and appropriateness of a patient's treatment plan and

601 drug therapies. The agency may contract with a private

602 organization to provide drug-program-management services. The

603 Medicaid drug benefit management program shall include

604 initiatives to manage drug therapies for HIV/AIDS patients,

605 patients using 20 or more unique prescriptions in a 180-day

606 period, and the top 1,000 patients in annual spending. The

607 agency shall enroll any Medicaid recipient in the drug benefit

608 management program if he or she meets the specifications of this

609 provision and is not enrolled in a Medicaid health maintenance

610 organization.

611 8.4. The agency may limit the size of its pharmacy network

612 based on need, competitive bidding, price negotiations,

613 credentialing, or similar criteria. The agency shall give

614 special consideration to rural areas in determining the size and

615 location of pharmacies included in the Medicaid pharmacy

616 network. A pharmacy credentialing process may include criteria

617 such as a pharmacy's full-service status, location, size,

618 patient educational programs, patient consultation, disease

619 management services, and other characteristics. The agency may

620 impose a moratorium on Medicaid pharmacy enrollment if it is

621 determined that it has a sufficient number of Medicaid-

622 participating providers. The agency must allow dispensing

623 practitioners to participate as a part of the Medicaid pharmacy

624 network regardless of the practitioner's proximity to any other

625 entity that is dispensing prescription drugs under the Medicaid

626 program. A dispensing practitioner must meet all credentialing

627 requirements applicable to his or her practice, as determined by

628 the agency.

629 9.5. The agency shall develop and implement a program that

630 requires Medicaid practitioners who issue written prescriptions

631 for medicinal drugs to use a counterfeit-proof prescription pad

632 for Medicaid prescriptions. The agency shall require the use of

633 standardized counterfeit-proof prescription pads by prescribers

634 who issue written prescriptions for Medicaid recipients. The

635 agency may implement the program in targeted geographic areas or

636 statewide.

637 10.6. The agency may enter into arrangements that require

638 manufacturers of generic drugs prescribed to Medicaid recipients

639 to provide rebates of at least 15.1 percent of the average

640 manufacturer price for the manufacturer's generic products.

641 These arrangements shall require that if a generic-drug

642 manufacturer pays federal rebates for Medicaid-reimbursed drugs

643 at a level below 15.1 percent, the manufacturer must provide a

644 supplemental rebate to the state in an amount necessary to

645 achieve a 15.1-percent rebate level.

646 11.7. The agency may establish a preferred drug list as

647 described in this subsection, and, pursuant to the establishment

648 of such preferred drug list, negotiate supplemental rebates from

649 manufacturers that are in addition to those required by Title

650 XIX of the Social Security Act and at no less than 14 percent of

651 the average manufacturer price as defined in 42 U.S.C. s. 1936

652 on the last day of a quarter unless the federal or supplemental

653 rebate, or both, equals or exceeds 29 percent. There is no upper

654 limit on the supplemental rebates the agency may negotiate. The

655 agency may determine that specific products, brand-name or

656 generic, are competitive at lower rebate percentages. Agreement

657 to pay the minimum supplemental rebate percentage guarantees a

658 manufacturer that the Medicaid Pharmaceutical and Therapeutics

659 Committee will consider a product for inclusion on the preferred

660 drug list. However, a pharmaceutical manufacturer is not

661 guaranteed placement on the preferred drug list by simply paying

662 the minimum supplemental rebate. Agency decisions will be made

663 on the clinical efficacy of a drug and recommendations of the

664 Medicaid Pharmaceutical and Therapeutics Committee, as well as

665 the price of competing products minus federal and state rebates.

666 The agency may contract with an outside agency or contractor to

667 conduct negotiations for supplemental rebates. For the purposes

668 of this section, the term "supplemental rebates" means cash

669 rebates. Value-added programs as a substitution for supplemental

670 rebates are prohibited. The agency may seek any federal waivers

671 to implement this initiative.

672 12.a.8.a. The agency may implement a Medicaid behavioral

673 drug management system. The agency may contract with a vendor

674 that has experience in operating behavioral drug management

675 systems to implement this program. The agency may seek federal

676 waivers to implement this program.

677 b. The agency, in conjunction with the Department of

678 Children and Families, may implement the Medicaid behavioral

679 drug management system that is designed to improve the quality

680 of care and behavioral health prescribing practices based on

681 best practice guidelines, improve patient adherence to

682 medication plans, reduce clinical risk, and lower prescribed

683 drug costs and the rate of inappropriate spending on Medicaid

684 behavioral drugs. The program may include the following

685 elements:

686 (I) Provide for the development and adoption of best

687 practice guidelines for behavioral health-related drugs such as

688 antipsychotics, antidepressants, and medications for treating

689 bipolar disorders and other behavioral conditions; translate

690 them into practice; review behavioral health prescribers and

691 compare their prescribing patterns to a number of indicators

692 that are based on national standards; and determine deviations

693 from best practice guidelines.

694 (II) Implement processes for providing feedback to and

695 educating prescribers using best practice educational materials

696 and peer-to-peer consultation.

697 (III) Assess Medicaid beneficiaries who are outliers in

698 their use of behavioral health drugs with regard to the numbers

699 and types of drugs taken, drug dosages, combination drug

700 therapies, and other indicators of improper use of behavioral

701 health drugs.

702 (IV) Alert prescribers to patients who fail to refill

703 prescriptions in a timely fashion, are prescribed multiple same-

704 class behavioral health drugs, and may have other potential

705 medication problems.

706 (V) Track spending trends for behavioral health drugs and

707 deviation from best practice guidelines.

708 (VI) Use educational and technological approaches to

709 promote best practices, educate consumers, and train prescribers

710 in the use of practice guidelines.

711 (VII) Disseminate electronic and published materials.

712 (VIII) Hold statewide and regional conferences.

713 (IX) Implement a disease management program with a model

714 quality-based medication component for severely mentally ill

715 individuals and emotionally disturbed children who are high

716 users of care.

717 13.9. The agency shall implement a Medicaid prescription

718 drug management system.

719 a. The agency may contract with a vendor that has

720 experience in operating prescription drug management systems in

721 order to implement this system. Any management system that is

722 implemented in accordance with this subparagraph must rely on

723 cooperation between physicians and pharmacists to determine

724 appropriate practice patterns and clinical guidelines to improve

725 the prescribing, dispensing, and use of drugs in the Medicaid

726 program. The agency may seek federal waivers to implement this

727 program.

728 b. The drug management system must be designed to improve

729 the quality of care and prescribing practices based on best

730 practice guidelines, improve patient adherence to medication

731 plans, reduce clinical risk, and lower prescribed drug costs and

732 the rate of inappropriate spending on Medicaid prescription

733 drugs. The program must:

734 (I) Provide for the adoption of best practice guidelines

735 for the prescribing and use of drugs in the Medicaid program,

736 including translating best practice guidelines into practice;

737 reviewing prescriber patterns and comparing them to indicators

738 that are based on national standards and practice patterns of

739 clinical peers in their community, statewide, and nationally;

740 and determine deviations from best practice guidelines.

741 (II) Implement processes for providing feedback to and

742 educating prescribers using best practice educational materials

743 and peer-to-peer consultation.

744 (III) Assess Medicaid recipients who are outliers in their

745 use of a single or multiple prescription drugs with regard to

746 the numbers and types of drugs taken, drug dosages, combination

747 drug therapies, and other indicators of improper use of

748 prescription drugs.

749 (IV) Alert prescribers to recipients who fail to refill

750 prescriptions in a timely fashion, are prescribed multiple drugs

751 that may be redundant or contraindicated, or may have other

752 potential medication problems.

753 14.10. The agency may contract for drug rebate

754 administration, including, but not limited to, calculating

755 rebate amounts, invoicing manufacturers, negotiating disputes

756 with manufacturers, and maintaining a database of rebate

757 collections.

758 15.11. The agency may specify the preferred daily dosing

759 form or strength for the purpose of promoting best practices

760 with regard to the prescribing of certain drugs as specified in

761 the General Appropriations Act and ensuring cost-effective

762 prescribing practices.

763 16.12. The agency may require prior authorization for

764 Medicaid-covered prescribed drugs. The agency may prior-

765 authorize the use of a product:

766 a. For an indication not approved in labeling;

767 b. To comply with certain clinical guidelines; or

768 c. If the product has the potential for overuse, misuse,

769 or abuse.

771 The agency may require the prescribing professional to provide

772 information about the rationale and supporting medical evidence

773 for the use of a drug. The agency shall post prior

774 authorization, step-edit criteria and protocol, and updates to

775 the list of drugs that are subject to prior authorization on the

776 agency's Internet website within 21 days after the prior

777 authorization and step-edit criteria and protocol and updates

778 are approved by the agency. For purposes of this subparagraph,

779 the term "step-edit" means an automatic electronic review of

780 certain medications subject to prior authorization.

781 17.13. The agency, in conjunction with the Pharmaceutical

782 and Therapeutics Committee, may require age-related prior

783 authorizations for certain prescribed drugs. The agency may

784 preauthorize the use of a drug for a recipient who may not meet

785 the age requirement or may exceed the length of therapy for use

786 of this product as recommended by the manufacturer and approved

787 by the Food and Drug Administration. Prior authorization may

788 require the prescribing professional to provide information

789 about the rationale and supporting medical evidence for the use

790 of a drug.

791 18.14. The agency shall implement a step-therapy prior

792 authorization approval process for medications excluded from the

793 preferred drug list. Medications listed on the preferred drug

794 list must be used within the previous 12 months before the

795 alternative medications that are not listed. The step-therapy

796 prior authorization may require the prescriber to use the

797 medications of a similar drug class or for a similar medical

798 indication unless contraindicated in the Food and Drug

799 Administration labeling. The trial period between the specified

800 steps may vary according to the medical indication. The step-

801 therapy approval process shall be developed in accordance with

802 the committee as stated in s. 409.91195(7) and (8). A drug

803 product may be approved without meeting the step-therapy prior

804 authorization criteria if the prescribing physician provides the

805 agency with additional written medical or clinical documentation

806 that the product is medically necessary because:

807 a. There is not a drug on the preferred drug list to treat

808 the disease or medical condition which is an acceptable clinical

809 alternative;

810 b. The alternatives have been ineffective in the treatment

811 of the beneficiary's disease;

812 c. The drug product or medication of a similar drug class

813 is prescribed for the treatment of schizophrenia or schizotypal

814 or delusional disorders; prior authorization has been granted

815 previously for the prescribed drug; and the medication was

816 dispensed to the patient during the previous 12 months; or

817 d. Based on historical evidence and known characteristics

818 of the patient and the drug, the drug is likely to be

819 ineffective, or the number of doses have been ineffective.

821 The agency shall work with the physician to determine the best

822 alternative for the patient. The agency may adopt rules waiving

823 the requirements for written clinical documentation for specific

824 drugs in limited clinical situations.

825 19.15. The agency shall implement a return and reuse

826 program for drugs dispensed by pharmacies to institutional

827 recipients, which includes payment of a $5 restocking fee for

828 the implementation and operation of the program. The return and

829 reuse program shall be implemented electronically and in a

830 manner that promotes efficiency. The program must permit a

831 pharmacy to exclude drugs from the program if it is not

832 practical or cost-effective for the drug to be included and must

833 provide for the return to inventory of drugs that cannot be

834 credited or returned in a cost-effective manner. The agency

835 shall determine if the program has reduced the amount of

836 Medicaid prescription drugs which are destroyed on an annual

837 basis and if there are additional ways to ensure more

838 prescription drugs are not destroyed which could safely be

839 reused.

840 (14) Neither this section nor this chapter prevents the

841 agency from conducting retrospective reviews, investigations,

842 analyses, audits, or any combination thereof to determine

843 possible fraud, abuse, overpayment, or recipient neglect in the

844 state Medicaid program pursuant to s. 409.913, including, but

845 not limited to, reviews in which the services were the subject

846 of a utilization review or prior authorization process.

847 Section 7. Paragraph (a) of subsection (4) and paragraph

848 (b) of subsection (6) of section 409.9122, Florida Statutes, are

849 amended to read:

850 409.9122 Medicaid managed care enrollment; HIV/AIDS

851 patients; procedures; data collection; accounting; information

852 system; medical loss ratio.—

853 (4) The agency shall maintain and operate the Medicaid

854 Encounter Data System to collect, process, store, and report on

855 covered services provided to all Florida Medicaid recipients

856 enrolled in prepaid managed care plans.

857 (a) ~~Prepaid~~ Managed care plans shall submit encounter

858 data, including denied encounters and encounters resulting from

859 a capitated arrangement, electronically in a format that

860 complies with the Health Insurance Portability and

861 Accountability Act provisions for electronic claims and in

862 accordance with deadlines established by the agency. ~~Prepaid~~

863 Managed care plans must certify that the data reported is

864 accurate and complete.

865 (6) The agency shall establish, and managed care plans

866 shall use, a uniform method of accounting for and reporting

867 medical and nonmedical costs.

868 (b) The agency is responsible for validating the financial

869 data submitted by the plans. The agency shall develop methods

870 and protocols for ongoing analysis of data that adjusts for

871 differences in characteristics of plan enrollees to allow

872 comparison among plans and against expected levels of

873 expenditures. The analysis shall be used to identify possible

874 cases of overspending on administrative costs, payment amounts

875 in excess of market rates, or underspending on medical services,

876 or potential managed care plan fraud, waste, and abuse. Such

877 analysis shall also be used in the rate setting process.

878 Section 8. Paragraph (e) of subsection (1) and subsections

879 (2) and (6) of section 409.913, Florida Statutes, are amended to read:

881 409.913 Oversight of the integrity of the Medicaid

882 program.—The agency shall operate a program to oversee the

883 activities of Florida Medicaid recipients, and providers and

884 their representatives, to ensure that fraudulent and abusive

885 behavior and neglect of recipients occur to the minimum extent

886 possible, and to recover overpayments and impose sanctions as

887 appropriate. Each January 15, the agency and the Medicaid Fraud

888 Control Unit of the Department of Legal Affairs shall submit a

889 report to the Legislature documenting the effectiveness of the

890 state's efforts to control Medicaid fraud and abuse and to

891 recover Medicaid overpayments during the previous fiscal year.

892 The report must describe the number of cases opened and

893 investigated each year; the sources of the cases opened; the

894 disposition of the cases closed each year; the amount of

895 overpayments alleged in preliminary and final audit letters; the

896 number and amount of fines or penalties imposed; any reductions

897 in overpayment amounts negotiated in settlement agreements or by

898 other means; the amount of final agency determinations of

899 overpayments; the amount deducted from federal claiming as a

900 result of overpayments; the amount of overpayments recovered

901 each year; the amount of cost of investigation recovered each

902 year; the average length of time to collect from the time the

903 case was opened until the overpayment is paid in full; the

904 amount determined as uncollectible and the portion of the

905 uncollectible amount subsequently reclaimed from the Federal

906 Government; the number of providers, by type, that are

907 terminated from participation in the Medicaid program as a

908 result of fraud and abuse; and all costs associated with

909 discovering and prosecuting cases of Medicaid overpayments and

910 making recoveries in such cases. The report must also document

911 actions taken to prevent overpayments and the number of

912 providers prevented from enrolling in or reenrolling in the

913 Medicaid program as a result of documented Medicaid fraud and

914 abuse and must include policy recommendations necessary to

915 prevent or recover overpayments and changes necessary to prevent

916 and detect Medicaid fraud. All policy recommendations in the

917 report must include a detailed fiscal analysis, including, but

918 not limited to, implementation costs, estimated savings to the

919 Medicaid program, and the return on investment. The agency must

920 submit the policy recommendations and fiscal analyses in the

921 report to the appropriate estimating conference, pursuant to s.

922 216.137, by February 15 of each year. The agency and the

923 Medicaid Fraud Control Unit of the Department of Legal Affairs

924 each must include detailed unit-specific performance standards,

925 benchmarks, and metrics in the report, including projected cost

926 savings to the state Medicaid program during the following

927 fiscal year.

928 (1) For the purposes of this section, the term:

929 (e) "Overpayment" includes any amount that is not

930 authorized to be paid by the Medicaid program or that should not

931 have been paid, including payments made ~~whether paid~~ as a result

932 of inaccurate or improper cost reporting, improper claiming,

933 unacceptable practices, fraud, abuse, or mistake, and may

934 include amounts paid for goods or services that were the subject

935 of a utilization review or prior authorization process.

936 (2) The agency shall conduct, or cause to be conducted by

937 contract or otherwise, reviews, investigations, analyses,

938 audits, or any combination thereof, to determine possible fraud,

939 abuse, overpayment, or recipient neglect in the Medicaid program

940 and shall report the findings of any overpayments in audit

941 reports as appropriate. An overpayment determination may be

942 based upon retrospective reviews, investigations, analyses,

943 audits, or any combination thereof to determine possible fraud,

944 abuse, overpayment, or recipient neglect in the Medicaid

945 program. At least 5 percent of all audits shall be conducted on

946 a random basis. As part of its ongoing fraud detection

947 activities, the agency shall identify and monitor, by contract

948 or otherwise, patterns of overutilization of Medicaid services

949 based on state averages. The agency shall track Medicaid

950 provider prescription and billing patterns and evaluate them

951 against Medicaid medical necessity criteria and coverage and

952 limitation guidelines adopted by rule. Medical necessity

953 determination requires that service be consistent with symptoms

954 or confirmed diagnosis of illness or injury under treatment and

955 not in excess of the patient's needs. The agency shall conduct

956 reviews of provider exceptions to peer group norms and shall,

957 using statistical methodologies, provider profiling, and

958 analysis of billing patterns, detect and investigate abnormal or

959 unusual increases in billing or payment of claims for Medicaid

960 services and medically unnecessary provision of services.

961 (6) Any notice required to be given to a provider under

962 this section is presumed to be sufficient notice if sent to the

963 mailing address last shown on the provider enrollment file. It

964 is the responsibility of the provider to furnish and keep the

965 agency informed of the provider's current mailing and service

966 addresses ~~address.~~ United States Postal Service or other common

967 carrier's proof of mailing or certified or registered mailing of

968 such notice to the provider at the address shown on the provider

969 enrollment file constitutes sufficient proof of notice. Any

970 notice required to be given to the agency by this section must

971 be sent to the agency at an address designated by rule.

972 Section 9. Present subsections (2) through (18) of section

973 409.962, Florida Statutes, are redesignated as subsections (3)

974 through (19), respectively, and a new subsection (2) is added to

975 that section, to read:

976 409.962 Definitions.—As used in this part, except as

977 otherwise specifically provided, the term:

978 (2) "Affiliate," including the terms "affiliated with" and

979 "affiliation," means a person, as construed in s. 1.01(3), who:

980 (a) Directly or indirectly, through one or more

981 intermediaries, controls, is controlled by, or is under common

982 control with a specified entity or person. The term includes

983 parent and subsidiary entities; or

984 (b) Is deemed a "related party" according to the standards

985 adopted by the Financial Accounting Standards Board.

986 Section 10. Subsections (1) and (2) and paragraph (h) of

987 subsection (3) of section 409.967, Florida Statutes, are

988 amended, and subsection (5) is added to that section, to read:

989 409.967 Managed care plan accountability.—

990 (1) CONTRACT PROCUREMENT PROCESS.—Beginning with the

991 contract procurement process initiated during the 2023 calendar

992 year, the agency shall establish a 6-year contract with each

993 managed care plan selected through the procurement process

994 described in s. 409.966. A plan contract may not be renewed;

995 however, the agency may extend the term of a plan contract to

996 cover any delays during the transition to a new plan. The agency

997 shall extend until December 31, 2024, the term of existing plan

998 contracts awarded pursuant to the invitation to negotiate

999 published in July 2017.

1000 (2) CONTRACT REQUIREMENTS.—The agency shall establish such

1001 contract requirements as are necessary for the operation of the

1002 statewide managed care program. The contracts must require any

1003 third-party administrative entity contracted by a plan to adhere

1004 to all requirements specific to the state Medicaid program. In

1005 addition to any other provisions the agency may deem necessary,

1006 the contract must require:

1007 (a) Physician compensation.—Managed care plans are

1008 expected to coordinate care, manage chronic disease, and prevent

1009 the need for more costly services. Effective care management

1010 should enable plans to redirect available resources and increase

1011 compensation for physicians. Plans achieve this performance

1012 standard when physician payment rates equal or exceed Medicare

1013 rates for similar services. The agency may impose fines or other

1014 sanctions on a plan that fails to meet this performance standard

1015 after 2 years of continuous operation.

1016 (b) Emergency services.—Managed care plans shall pay for

1017 services required by ss. 395.1041 and 401.45 and rendered by a

1018 noncontracted provider. The plans must comply with s. 641.3155.

1019 Reimbursement for services under this paragraph is the lesser

1020 of:

1021 1. The provider's charges;

1022 2. The usual and customary provider charges for similar

1023 services in the community where the services were provided;

1024 3. The charge mutually agreed to by the entity and the

1025 provider within 60 days after submittal of the claim; or

1026 4. The Medicaid rate, which, for the purposes of this

1027 paragraph, means the amount the provider would collect from the

1028 agency on a fee-for-service basis, less any amounts for the

1029 indirect costs of medical education and the direct costs of

1030 graduate medical education that are otherwise included in the

1031 agency's fee-for-service payment, as required under 42 U.S.C. s.

1032 1396u-2(b)(2)(D). For the purpose of establishing the amounts

1033 specified in this subparagraph, the agency shall publish on its

1034 website annually, or more frequently as needed, the applicable

1035 fee-for-service fee schedules and their effective dates, less

1036 any amounts for indirect costs of medical education and direct

1037 costs of graduate medical education that are otherwise included

1038 in the agency's fee-for-service payments.

1039 (c) Access.—

1040 1. The agency shall establish specific standards for the

1041 number, type, and regional distribution of providers in managed

1042 care plan networks to ensure access to care for both adults and

1043 children. Each plan must maintain a regionwide network of

1044 providers in sufficient numbers to meet the access standards for

1045 specific medical services for all recipients enrolled in the

1046 plan. The exclusive use of mail-order pharmacies may not be

1047 sufficient to meet network access standards. Consistent with the

1048 standards established by the agency, provider networks may

1049 include providers located outside the region. Each plan shall

1050 establish and maintain an accurate and complete electronic

1051 database of contracted providers, including information about

1052 licensure or registration, locations and hours of operation,

1053 specialty credentials and other certifications, specific

1054 performance indicators, and such other information as the agency

1055 deems necessary. The database must be available online to both

1056 the agency and the public and have the capability to compare the

1057 availability of providers to network adequacy standards and to

1058 accept and display feedback from each provider's patients. Each

1059 plan shall submit quarterly reports to the agency identifying

1060 the number of enrollees assigned to each primary care provider.

1061 The agency shall conduct, or contract for, systematic and

1062 continuous testing of the provider network databases maintained

1063 by each plan to confirm accuracy, confirm that behavioral health

1064 providers are accepting enrollees, and confirm that enrollees

1065 have access to behavioral health services.

1066 2. Each managed care plan must publish any prescribed drug

1067 formulary or preferred drug list on the plan's website in a

1068 manner that is accessible to and searchable by enrollees and

1069 providers. The plan must update the list within 24 hours after

1070 making a change. Each plan must ensure that the prior

1071 authorization process for prescribed drugs is readily accessible

1072 to health care providers, including posting appropriate contact

1073 information on its website and providing timely responses to

1074 providers. For Medicaid recipients diagnosed with hemophilia who

1075 have been prescribed anti-hemophilic-factor replacement

1076 products, the agency shall provide for those products and

1077 hemophilia overlay services through the agency's hemophilia

1078 disease management program.

1079 3. Managed care plans, and their fiscal agents or

1080 intermediaries, must accept prior authorization requests for any

1081 service electronically.

1082 4. Managed care plans serving children in the care and

1083 custody of the Department of Children and Families must maintain

1084 complete medical, dental, and behavioral health encounter

1085 information and participate in making such information available

1086 to the department or the applicable contracted community-based

1087 care lead agency for use in providing comprehensive and

1088 coordinated case management. The agency and the department shall

1089 establish an interagency agreement to provide guidance for the

1090 format, confidentiality, recipient, scope, and method of

1091 information to be made available and the deadlines for

1092 submission of the data. The scope of information available to

1093 the department shall be the data that managed care plans are

1094 required to submit to the agency. The agency shall determine the

1095 plan's compliance with standards for access to medical, dental,

1096 and behavioral health services; the use of medications; and

1097 followup on all medically necessary services recommended as a

1098 result of early and periodic screening, diagnosis, and

1099 treatment.

1100 (d) Quality care.—Managed care plans shall provide, or

1101 contract for the provision of, care coordination to facilitate

1102 the appropriate delivery of behavioral health care services in

1103 the least restrictive setting with treatment and recovery

1104 capabilities that address the needs of the patient. Services

1105 shall be provided in a manner that integrates behavioral health

1106 services and primary care. Plans shall be required to achieve

1107 specific behavioral health outcome standards, established by the

1108 agency in consultation with the department.

1109 (e) Encounter data.—The agency shall maintain and operate

1110 a Medicaid Encounter Data System to collect, process, store, and

1111 report on covered services provided to all Medicaid recipients

1112 enrolled in prepaid plans.

1113 1. Each prepaid plan must comply with the agency's

1114 reporting requirements for the Medicaid Encounter Data System.

1115 Prepaid plans must submit encounter data electronically in a

1116 format that complies with the Health Insurance Portability and

1117 Accountability Act provisions for electronic claims and in

1118 accordance with deadlines established by the agency. Prepaid

1119 plans must certify that the data reported is accurate and

1120 complete.

1121 2. The agency is responsible for validating the data

1122 submitted by the plans. The agency shall develop methods and

1123 protocols for ongoing analysis of the encounter data that

1124 adjusts for differences in characteristics of prepaid plan

1125 enrollees to allow comparison of service utilization among plans

1126 and against expected levels of use. The analysis shall be used

1127 to identify possible cases of systemic underutilization or

1128 denials of claims and inappropriate service utilization such as

1129 higher-than-expected emergency department encounters. The

1130 analysis shall provide periodic feedback to the plans and enable

1131 the agency to establish corrective action plans when necessary.

1132 One of the focus areas for the analysis shall be the use of

1133 prescription drugs.

1134 3. The agency shall make encounter data available to those

1135 plans accepting enrollees who are assigned to them from other

1136 plans leaving a region.

1137 4. The agency shall annually produce a report entitled

1138 "Analysis of Potentially Preventable Health Care Events of

1139 Florida Medicaid Enrollees." The report must include, but need

1140 not be limited to, an analysis of the potentially preventable

1141 hospital emergency department visits, hospital admissions, and

1142 hospital readmissions that occurred during the previous state

1143 fiscal year which may have been prevented with better access to

1144 primary care, improved medication management, or better

1145 coordination of care, reported by age, eligibility group,

1146 managed care plan, and region, including conditions contributing

1147 to each potentially preventable event or category of potentially

1148 preventable events. The agency may include any other data or

1149 analysis parameters to augment the report which it deems

1150 pertinent to the analysis. The report must demonstrate trends

1151 using applicable historical data. The agency shall submit the

1152 report to the Governor, the President of the Senate, and the

1153 Speaker of the House of Representatives by October 1, 2024, and

1154 each October 1 thereafter. The agency may contract with a third-

1155 party vendor to produce the report required under this

1156 subparagraph.

1157 (f) Continuous improvement.—The agency shall establish

1158 specific performance standards and expected milestones or

1159 timelines for improving performance over the term of the

1160 contract.

1161 1. Each managed care plan shall establish an internal

1162 health care quality improvement system, including enrollee

1163 satisfaction and disenrollment surveys. The quality improvement

1164 system must include incentives and disincentives for network

1165 providers.

1166 2. Each managed care plan must collect and report the

1167 Healthcare Effectiveness Data and Information Set (HEDIS)

1168 measures, the federal Core Set of Children's Health Care Quality

1169 measures, and the federal Core Set of Adult Health Care Quality

1170 Measures, as specified by the agency. Each plan must collect and

1171 report the Adult Core Set behavioral health measures beginning

1172 with data reports for the 2025 calendar year. Each plan must

1173 stratify reported measures by age, sex, race, ethnicity, primary

1174 language, and whether the enrollee received a Social Security

1175 Administration determination of disability for purposes of

1176 Supplemental Security Income beginning with data reports for the

1177 2026 calendar year. A plan's performance on these measures must

1178 be published on the plan's website in a manner that allows

1179 recipients to reliably compare the performance of plans. The

1180 agency shall use the measures as a tool to monitor plan

1181 performance.

1182 3. Each managed care plan must be accredited by the

1183 National Committee for Quality Assurance, the Joint Commission,

1184 or another nationally recognized accrediting body, or have

1185 initiated the accreditation process, within 1 year after the

1186 contract is executed. For any plan not accredited within 18

1187 months after executing the contract, the agency shall suspend

1188 automatic assignment under ss. 409.977 and 409.984.

1189 (g) Program integrity.—Each managed care plan shall

1190 establish program integrity functions and activities to reduce

1191 the incidence of fraud and abuse, including, at a minimum:

1192 1. A provider credentialing system and ongoing provider

1193 monitoring, including maintenance of written provider

1194 credentialing policies and procedures which comply with federal

1195 and agency guidelines;

1196 2. An effective prepayment and postpayment review process

1197 including, but not limited to, data analysis, system editing,

1198 and auditing of network providers;

1199 3. Procedures for reporting instances of fraud and abuse

1200 pursuant to chapter 641;

1201 4. Administrative and management arrangements or

1202 procedures, including a mandatory compliance plan, designed to

1203 prevent fraud and abuse; and

1204 5. Designation of a program integrity compliance officer.

1205 (h) Grievance resolution.—Consistent with federal law,

1206 each managed care plan shall establish and the agency shall

1207 approve an internal process for reviewing and responding to

1208 grievances from enrollees. Each plan shall submit quarterly

1209 reports on the number, description, and outcome of grievances

1210 filed by enrollees.

1211 (i) Penalties.—

1212 1. Withdrawal and enrollment reduction.—Managed care plans

1213 that reduce enrollment levels or leave a region before the end

1214 of the contract term must reimburse the agency for the cost of

1215 enrollment changes and other transition activities. If more than

1216 one plan leaves a region at the same time, costs must be shared

1217 by the departing plans proportionate to their enrollments. In

1218 addition to the payment of costs, departing provider services

1219 networks must pay a per-enrollee penalty of up to 3 months'

1220 payment and continue to provide services to the enrollee for 90

1221 days or until the enrollee is enrolled in another plan,

1222 whichever occurs first. In addition to payment of costs, all

1223 other departing plans must pay a penalty of 25 percent of that

1224 portion of the minimum surplus maintained pursuant to s.

1225 641.225(1) which is attributable to the provision of coverage to

1226 Medicaid enrollees. Plans shall provide at least 180 days'

1227 notice to the agency before withdrawing from a region. If a

1228 managed care plan leaves a region before the end of the contract

1229 term, the agency shall terminate all contracts with that plan in

1230 other regions pursuant to the termination procedures in

1231 subparagraph 3.

1232 2. Encounter data.—If a plan fails to comply with the

1233 encounter data reporting requirements of this section for 30

1234 days, the agency must assess a fine of $5,000 per day for each

1235 day of noncompliance beginning on the 31st day. On the 31st day,

1236 the agency must notify the plan that the agency will initiate

1237 contract termination procedures on the 90th day unless the plan

1238 comes into compliance before that date.

1239 3. Termination.—If the agency terminates more than one

1240 regional contract with the same managed care plan due to

1241 noncompliance with the requirements of this section, the agency

1242 shall terminate all the regional contracts held by that plan.

1243 When terminating multiple contracts, the agency must develop a

1244 plan to provide for the transition of enrollees to other plans,

1245 and phase in the terminations over a time period sufficient to

1246 ensure a smooth transition.

1247 (j) Prompt payment.—Managed care plans shall comply with

1248 ss. 641.315, 641.3155, and 641.513.

1249 (k) Electronic claims.—Managed care plans, and their

1250 fiscal agents or intermediaries, shall accept electronic claims

1251 in compliance with federal standards.

1252 (l) Fair payment.—Provider service networks must ensure

1253 that no entity licensed under chapter 395 with a controlling

1254 interest in the network charges a Medicaid managed care plan

1255 more than the amount paid to that provider by the provider

1256 service network for the same service.

1257 (m) Itemized payment.—Any claims payment to a provider by

1258 a managed care plan, or by a fiscal agent or intermediary of the

1259 plan, must be accompanied by an itemized accounting of the

1260 individual claims included in the payment including, but not

1261 limited to, the enrollee's name, the date of service, the

1262 procedure code, the amount of reimbursement, and the

1263 identification of the plan on whose behalf the payment is made.

1264 (n) Provider dispute resolution.—Disputes between a plan

1265 and a provider may be resolved as described in s. 408.7057.

1266 (o) Transparency.—Managed care plans shall comply with ss.

1267 627.6385(3) and 641.54(7).

1268 (3) ACHIEVED SAVINGS REBATE.—

1269 (h) The following may not be included as allowable

1270 expenses in calculating income for determining the achieved

1271 savings rebate:

1272 1. Payment of achieved savings rebates.

1273 2. Any financial incentive payments made to the plan

1274 outside of the capitation rate.

1275 3. Any financial disincentive payments levied by the state

1276 or Federal Government.

1277 4. Expenses associated with any lobbying or political

1278 activities.

1279 5. The cash value or equivalent cash value of bonuses of

1280 any type paid or awarded to the plan's executive staff, other

1281 than base salary.

1282 6. Reserves and reserve accounts.

1283 7. Administrative costs, including, but not limited to,

1284 reinsurance expenses, interest payments, depreciation expenses,

1285 bad debt expenses, and outstanding claims expenses in excess of

1286 actuarially sound maximum amounts set by the agency.

1287 8. Payments to affiliated entities as defined in s.

1288 409.962 in excess of market rates, as determined by the agency.

1290 The agency shall consider these and other factors in developing

1291 contracts that establish shared savings arrangements.

1292 (5) AFFILIATED ENTITIES AND RELATED PARTIES.—

1293 (a) The agency shall ensure oversight of affiliated

1294 entities and related parties as defined in s. 409.962 within the

1295 Statewide Medicaid Managed Care program. This includes, but is

1296 not limited to, examining financial records and self-referral

1297 data for any managed care plan providing services within the

1298 Statewide Medicaid Managed Care program utilizing affiliated

1299 entities and related parties within their business model.

1300 (b) The agency shall consider data obtained pursuant to

1301 paragraph (a) and the findings of the annual assessment required

1302 under s. 409.9675(3) when determining the final medical loss

1303 ratio as specified in subsection (4) and during the rate setting

1304 process. Section 11. Section 409.9675, Florida Statutes, is created

1306 to read:

1307 409.9675 Affiliated entities and controlling interest;

1308 reports required.—

1309 (1) As used in this part, the term "control," including

1310 the terms "controlling," "controlled by," and "under common

1311 control with," means the possession, direct or indirect, of the

1312 power to direct or cause the direction of the management and

1313 policies of a person, whether through the ownership or voting

1314 securities, by contract other than a commercial contract for

1315 goods or nonmanagement services, or otherwise, unless the power

1316 is the result of an official position with or corporate office

1317 held by the person. This definition applies regardless of

1318 whether such power is affirmative or negative or whether such

1319 power is actually used. Control is presumed to exist, but is not

1320 limited to, when any affiliate or person, as construed in s.

1321 1.01(3):

1322 (a) Directly or indirectly owns, controls, holds the power

1323 to vote, or holds proxies representing 10 percent or more of any

1324 class of the voting securities of any other person.

1325 (b) Shares common ownership with any person, has an

1326 investor or is a holder of an ownership interest in any person,

1327 exercises control in any manner over the election of a majority

1328 of the directors or of individuals exercising similar functions

1329 of any person, has the power to exercise controlling influence

1330 over the management of any person, or serves as a working

1331 majority of the board of directors, managers, or the officers of

1332 a person, who is:

1333 1. A provider or a member of a provider group or group

1334 practice as defined in s. 456.053 under the managed care plan;

1335 or

1336 2. A person responsible for providing any pharmacy

1337 services, pharmaceuticals, diagnostics, care coordination, care

1338 delivery, health care services, medical equipment,

1339 administrative services, or financial services under the managed

1340 care plan.

1341 (2) By March 31, 2027, and annually thereafter, each

1342 managed care plan shall report to the agency and the Office of

1343 Insurance Regulation, in the manner prescribed by the agency,

1344 all of the following:

1345 (a) Any person, as construed in s. 1.01(3), controlled by

1346 or affiliated with the managed care plan, including, but not

1347 limited to, any provider, provider group, group practice as

1348 defined in s. 456.053(3), or person responsible for providing

1349 any pharmacy services, pharmaceuticals, diagnostics, care

1350 coordination, care delivery, health care services, medical

1351 equipment, administrative services, or financial services for,

1352 to, or on behalf of the managed care plan.

1353 (b) Any affiliation of any kind or nature with any person,

1354 as construed in s. 1.01(3), which, either directly or

1355 indirectly, through one or more intermediaries has an investment

1356 or ownership interest representing 10 percent or more, shares

1357 common ownership, or has an investor or a holder of an ownership

1358 interest representing 10 percent or more, with any person

1359 providing pharmacy services, diagnostics, care coordination,

1360 care delivery, health care services, medical equipment,

1361 administrative services, or financial services for, to, or on

1362 behalf of the managed care plan.

1363 (c) For any affiliation reported under paragraph (a) or

1364 paragraph (b), the report must include all of the following:

1365 1. The percentage of ownership or control of any person or

1366 affiliate with whom the managed care plan or prepaid plan has

1367 had business transactions during the 12-month period in the

1368 annual achieved savings rebate financial reporting required

1369 under s. 409.967(3) and identification of the services provided

1370 under the contract or contracts involved in such business

1371 transactions; and

1372 2. Any significant business transactions between the

1373 managed care plan and any affiliated person during the 12-month

1374 period in the annual financial reporting required under s.

1375 409.967(3).

1376 (3) Each managed care plan shall report any change in

1377 information required by subsection (1) to the agency and the

1378 Office of Insurance Regulation in writing within 60 days after

1379 such change occurs.

1380 (4) By December 31, 2026, and annually thereafter, the

1381 agency shall calculate, analyze, and publicly report on the

1382 agency's website an assessment of affiliated entity payment

1383 transactions in the Medicaid program for medical benefit and

1384 administrative costs as reported for purposes of the achieved

1385 savings rebate. The baseline assessment, at a minimum, must

1386 include achieved savings rebate transactions for the years 2021,

1387 2022, and 2023; the amount and associated percentage of

1388 affiliated entity payments within the medical loss ratio; and

1389 the payment deviation percentages and associated amounts at the

1390 Healthcare Common Procedure Coding System level for affiliated

1391 entities as compared to nonaffiliated entities. The assessment

1392 must also compare payment amounts for value-based or alternative

1393 payment arrangements.

1394 Section 12. Paragraph (c) is added to subsection (5) of

1395 section 409.973, Florida Statutes, to read:

1396 409.973 Benefits.—

1397 (5) PROVISION OF DENTAL SERVICES.—

1398 (c) By July 1, 2027, the agency shall implement an

1399 Integrated Managed Care Pilot Program in which Medicaid

1400 recipients in designated regions of this state shall receive

1401 both medical and dental covered benefits through the same

1402 managed medical assistance plan.

1403 1. The agency shall submit a request for federal approval

1404 for the pilot program by August 1, 2026, and to implement the

1405 pilot program in Statewide Medicaid Managed Care Regions A and B

1406 by July 1, 2027, contingent upon federal approval.

1407 2. The agency is directed to amend contracts awarded to

1408 managed care plans for the provision of managed medical

1409 assistance services in Statewide Medicaid Managed Care Regions A

1410 and B to include coverage of state plan dental services

1411 effective upon implementation of the pilot program. Managed care

1412 plans providing managed medical assistance services in Regions A

1413 and B must begin providing dental services by July 1, 2027, for

1414 all Medicaid recipients in their region previously eligible for

1415 services under the statewide prepaid dental program and must

1416 comply with contractual continuity of care requirements. Managed

1417 care plans must also agree to provide the same level of service

1418 as the prepaid dental plans in their region, including expanded

1419 benefits offered by those plans at no cost to the state. Managed

1420 care plans that provide dental services in Regions A and B must

1421 maintain a minimum dental medical loss ratio of 85 percent,

1422 calculated in accordance with 42 C.F.R. 438.8. The agency shall

1423 separately identify the amounts included in the capitation rates

1424 for dental services. The managed care plans shall recognize

1425 existing provider credentialing performed by the prepaid dental

1426 plans for providers who remain in good standing with the state

1427 Medicaid program for a period not to exceed 12 months after the

1428 effective date of implementation of the pilot program. If a

1429 managed care plan fails to execute contracts or contract

1430 amendments needed to implement the pilot program, the agency

1431 must terminate all contracts with that plan. Contracts in

1432 Statewide Medicaid Managed Care Regions A and B which provide

1433 services under the statewide prepaid Medicaid dental health

1434 program authorized by paragraph (b) terminate upon

1435 implementation of the pilot program in these regions.

1436 3. The agency shall establish specific measures of access,

1437 quality, and costs for evaluations of the pilot program. The

1438 agency shall contract with an independent evaluator to conduct

1439 the program evaluations. The evaluations must compare the

1440 experience in the regions participating in the pilot program

1441 with the experience in the regions not participating in the

1442 pilot program. The evaluations must include consideration of all

1443 of the following, at a minimum:

1444 a. Utilization of routine preventive dental care,

1445 including routine preventive dental care provided as expanded

1446 benefits, and avoidable emergency or surgical dental services.

1447 b. Dental health outcomes and other associated health

1448 outcomes impacted by dental health.

1449 c. Recipient satisfaction and continuity of care.

1450 d. Impact on the provider network, including any increase

1451 in the number of dental practitioners willing to accept

1452 Medicaid.

1453 e. Costs of Medicaid services for the pilot program

1454 population with specific focus on utilization, outcomes, and

1455 costs associated with children and disabled populations.

1456 4. The agency shall submit a report on the performance of

1457 the pilot program to the Governor, the President of the Senate,

1458 and the Speaker of the House of Representatives beginning on

1459 December 1, 2028, and annually thereafter.

1460 Section 13. Subsection (1) of section 409.91196, Florida

1461 Statutes, is amended to read:

1462 409.91196 Supplemental rebate agreements; public records

1463 and public meetings exemption.—

1464 (1) The rebate amount, percent of rebate, manufacturer's

1465 pricing, and supplemental rebate, and other trade secrets as

1466 defined in s. 688.002 that the agency has identified for use in

1467 negotiations, held by the Agency for Health Care Administration

1468 under s. 409.912(5)(a)11. ~~s. 409.912(5)(a)7.~~ are confidential

1469 and exempt from s. 119.07(1) and s. 24(a), Art. I of the State

1470 Constitution.

1471 Section 14. Subsection (1) of section 627.42392, Florida

1472 Statutes, is amended to read:

1473 627.42392 Prior authorization.—

1474 (1) As used in this section, the term "health insurer"

1475 means an authorized insurer offering health insurance as defined

1476 in s. 624.603, a managed care plan as defined in s. 409.962(12)

1477 ~~s. 409.962(10),~~ or a health maintenance organization as defined

1478 in s. 641.19(12).

1479 Section 15. This act shall take effect July 1, 2026.