No. HB 1453
Filed under Healthcare.
State Medicaid Program; Authorizes AHCA to conduct retrospective reviews & audits of certain claims under state Medicaid program for specified purpose; requires agency, in coordination with DCF, to implement mandatory work & community engagement requirements for able-bodied adults as condition of obtaining & maintaining Medicaid coverage; specifies types of activities which may satisfy work & community engagement requirements; provides that certain population is required to engage in work or community engagement activities only during standard school hours; requires persons eligible for Medicaid to demonstrate compliance with work & community engagement requirements at specified times as condition of maintaining Medicaid coverage; revises components of Medicaid prescribed-drug spending-control program to include preferred physician-administered drug list, preferred product list, & high-cost drug list; provides that determinations of overpayment under Medicaid program may be based upon retrospective reviews, investigations, analyses, or audits conducted by agency to determine possible fraud, abuse, overpayment, or recipient neglect; requires agency to implement Integrated Managed Care Pilot Program in designated regions by specified date.
Plain English Summary
AI-GENERATEDAdults 18 to 64 on Medicaid must complete 80 hours a month of work, job training, or school to keep coverage, unless they fall under an exemption such as caretaker of a young child, veteran with total disability, or pregnancy.
Recipients who fall behind get a 30-day grace period, then lose coverage at month's end if they still have not complied. They can request a hearing or reapply, and parents of children 6 to 18 only owe hours during school time.
The state can find a Medicaid overpayment even on claims that already passed prior authorization or utilization review, and can retroactively audit emergency-care claims for noncitizens regardless of prior approval.
Managed care plans must disclose ownership ties to affiliated providers and pharmacies, and a new pilot will combine medical and dental coverage in two regions, with plans that balk losing all their Medicaid contracts.
AIAble-bodied adults 18-64 must complete 80 hours a month of work, training, or school to obtain or keep Medicaid coverage, unless they fall under a listed exemption such as caring for a young child or being medically frail.
AIA recipient found out of compliance gets a 30-day grace period to comply or claim an exemption while coverage continues. If they still haven't complied by the deadline, their case is denied and services end the following month.
AIAHCA's overpayment determinations may rest on retrospective audits of claims that already went through prior authorization or utilization review, so a provider that followed the pre-approval process is not shielded from a later clawback.
AIEach Medicaid managed care plan must report yearly to AHCA and the Office of Insurance Regulation any provider, pharmacy, or other business it controls or is affiliated with, including any 10-percent-or-greater ownership tie.
AIAHCA may retrospectively review or audit services billed under a noncitizen's emergency Medicaid coverage to check whether the emergency was real and the care necessary, regardless of whether the provider had prior authorization.
AIAHCA must examine a managed care plan's financial records and self-referral data where the plan uses affiliated or related-party businesses, and factor the findings into the plan's medical loss ratio and future rate-setting.
AIBy July 2027, two regions get a pilot combining medical and dental Medicaid coverage under one plan. A managed care plan that will not execute the needed contract changes loses every Medicaid contract it holds, not only the pilot ones.
AIHospitals administering long-acting injectable drugs for severe mental illness are paid separately from the usual bundled hospital rate, at no less than the drug's actual acquisition cost.