SB 152 full text · Session Watch

Florida Senate - 2026 SB 152 By Senator Harrell 31-00500-26 2026152__

1 A bill to be entitled

2 An act relating to Medicaid provider networks;

3 amending s. 409.908, F.S.; requiring Medicaid managed

4 care plans and providers to negotiate mutually

5 acceptable rates, methods, and terms of payment for

6 purposes of Medicaid reimbursements; requiring plans

7 to pay dentists at certain rates; amending s. 409.967,

8 F.S.; specifying additional requirements for the

9 provider network contracts under the statewide managed

10 care program; amending ss. 409.9071, 427.0135, and

11 1011.70, F.S.; conforming cross-references; reenacting

12 ss. 409.966(3)(c), 409.975(1), and 409.9855(4)(b),

13 F.S., relating to eligible managed care plans, managed

14 care plan accountability, and the pilot program for

15 individuals with developmental disabilities,

16 respectively, to incorporate the amendment made to s.

17 409.967, F.S., in references thereto; providing an

18 effective date.

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

22 Section 1. Present subsections (11) through (26) of section

23 409.908, Florida Statutes, are redesignated as subsections (12)

24 through (27), respectively, and a new subsection (11) is added

25 to that section, to read:

26 409.908 Reimbursement of Medicaid providers.—Subject to

27 specific appropriations, the agency shall reimburse Medicaid

28 providers, in accordance with state and federal law, according

29 to methodologies set forth in the rules of the agency and in

30 policy manuals and handbooks incorporated by reference therein.

31 These methodologies may include fee schedules, reimbursement

32 methods based on cost reporting, negotiated fees, competitive

33 bidding pursuant to s. 287.057, and other mechanisms the agency

34 considers efficient and effective for purchasing services or

35 goods on behalf of recipients. If a provider is reimbursed based

36 on cost reporting and submits a cost report late and that cost

37 report would have been used to set a lower reimbursement rate

38 for a rate semester, then the provider’s rate for that semester

39 shall be retroactively calculated using the new cost report, and

40 full payment at the recalculated rate shall be effected

41 retroactively. Medicare-granted extensions for filing cost

42 reports, if applicable, shall also apply to Medicaid cost

43 reports. Payment for Medicaid compensable services made on

44 behalf of Medicaid-eligible persons is subject to the

45 availability of moneys and any limitations or directions

46 provided for in the General Appropriations Act or chapter 216.

47 Further, nothing in this section shall be construed to prevent

48 or limit the agency from adjusting fees, reimbursement rates,

49 lengths of stay, number of visits, or number of services, or

50 making any other adjustments necessary to comply with the

51 availability of moneys and any limitations or directions

52 provided for in the General Appropriations Act, provided the

53 adjustment is consistent with legislative intent.

54 (11) Managed care plans and providers shall negotiate

55 mutually acceptable rates, methods, and terms of payment. Plans

56 shall pay dentists an amount equal to or higher than the dental

57 payment rates set by the agency.

58 Section 2. Paragraph (c) of subsection (2) of section

59 409.967, Florida Statutes, is amended to read:

60 409.967 Managed care plan accountability.—

61 (2) The agency shall establish such contract requirements

62 as are necessary for the operation of the statewide managed care

63 program. In addition to any other provisions the agency may deem

64 necessary, the contract must require:

65 (c) Access.—

66 1. The agency shall establish specific standards for the

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

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

69 children. Each plan must maintain a regionwide network of

70 providers in sufficient numbers to meet the access standards for

71 specific medical services for all recipients enrolled in the

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

73 sufficient to meet network access standards. Consistent with the

74 standards established by the agency, provider networks may

75 include providers located outside the region. Each plan shall

76 establish and maintain an accurate and complete electronic

77 database of contracted providers, including information about

78 licensure or registration, locations and hours of operation,

79 specialty credentials and other certifications, specific

80 performance indicators, and such other information as the agency

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

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

83 availability of providers to network adequacy standards and to

84 accept and display feedback from each provider’s patients. Each

85 plan shall submit quarterly reports to the agency identifying

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

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

88 continuous testing of the provider network databases maintained

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

90 providers are accepting enrollees, and confirm that enrollees

91 have access to behavioral health services.

92 a. A dentist may appear on the provider network database as

93 an active Medicaid provider only if he or she devotes a minimum

94 average of 20 hours per week of direct patient care at the

95 location where he or she is listed as an active Medicaid

96 provider.

97 b. A secondary provider network may be published on the

98 database for those providers who offer less than the minimum

99 average of 20 hours per week of direct patient care at the

100 location where they are listed as a provider.

101 c. A provider may not be listed on the network provider

102 database if he or she offers less than 4 hours per week of

103 direct patient care to beneficiaries of the Medicaid program at

104 the indicated location.

105 d. Specialty care providers must be listed separately from

106 general dentists on the network provider database and must be

107 listed under the specialty they provide.

108 e. If a group practice or university employs or uses

109 multiple dental providers, each working less than the parameters

110 established in sub-subparagraphs a.-c., that group practice or

111 university must be listed on the network provider database as a

112 single entity provider and may not have each dental provider

113 listed individually.

114 f. Each provider in the network provider database must

115 indicate what services he or she provides and whether the

116 practice is accepting new patients for each of those services.

117 This information must also specify the location at which the

118 services are provided. Endodontists, oral surgeons, and

119 periodontists must specify the age range for each of the

120 services they provide.

121 g. To ensure true adequacy and access of care, dental plans

122 must categorize and report provider availability more

123 specifically, listing which of the following services is

124 provided by each provider, including specialists:

125 (I) Preventive care.

126 (II) Restorative care.

127 (III) Conscious sedation, specifying whether nitrous oxide

128 or oral sedation, or both, are offered.

129 (IV) In-office anesthesia, specifying whether intravenous

130 sedation or general anesthesia, or both, are offered.

131 (V) Access to emergent care, specifying whether the

132 provider has access to an ambulatory surgical center, a general

133 hospital, or a children’s hospital.

135 If a provider provides any of the services specified in this

136 sub-subparagraph, the dental plan must disclose whether the

137 provider is experienced in and willing to provide such care to

138 patients with intellectual or developmental disabilities and

139 whether there are any age or other limitations on such services.

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

141 formulary or preferred drug list on the plan’s website in a

142 manner that is accessible to and searchable by enrollees and

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

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

145 authorization process for prescribed drugs is readily accessible

146 to health care providers, including posting appropriate contact

147 information on its website and providing timely responses to

148 providers. For Medicaid recipients diagnosed with hemophilia who

149 have been prescribed anti-hemophilic-factor replacement

150 products, the agency shall provide for those products and

151 hemophilia overlay services through the agency’s hemophilia

152 disease management program.

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

154 intermediaries, must accept prior authorization requests for any

155 service electronically.

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

157 custody of the Department of Children and Families must maintain

158 complete medical, dental, and behavioral health encounter

159 information and participate in making such information available

160 to the department or the applicable contracted community-based

161 care lead agency for use in providing comprehensive and

162 coordinated case management. The agency and the department shall

163 establish an interagency agreement to provide guidance for the

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

165 information to be made available and the deadlines for

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

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

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

169 plan’s compliance with standards for access to medical, dental,

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

171 follow-up care ~~followup~~ on all medically necessary services

172 recommended as a result of early and periodic screening,

173 diagnosis, and treatment.

174 Section 3. Subsection (1) of section 409.9071, Florida

175 Statutes, is amended to read:

176 409.9071 Medicaid provider agreements for school districts

177 certifying state match.—

178 (1) The agency shall reimburse school-based services as

179 provided in ss. 409.908(22) and 1011.70 ~~ss. 409.908(21) and~~

180 ~~1011.70~~ pursuant to the rehabilitative services option provided

181 under 42 U.S.C. s. 1396d(a)(13). For purposes of this section,

182 billing agent consulting services are considered billing agent

183 services, as that term is used in s. 409.913(10), and, as such,

184 payments to such persons may not be based on amounts for which

185 they bill nor based on the amount a provider receives from the

186 Medicaid program. This provision may not restrict privatization

187 of Medicaid school-based services. Subject to any limitations

188 provided for in the General Appropriations Act, the agency, in

189 compliance with appropriate federal authorization, shall develop

190 policies and procedures and shall allow for certification of

191 state and local education funds that have been provided for

192 school-based services as specified in s. 1011.70 and authorized

193 by a physician’s order where required by federal Medicaid law.

194 Section 4. Subsection (3) of section 427.0135, Florida

195 Statutes, is amended to read:

196 427.0135 Purchasing agencies; duties and responsibilities.

197 Each purchasing agency, in carrying out the policies and

198 procedures of the commission, shall:

199 (3) Not procure transportation disadvantaged services

200 without initially negotiating with the commission, as provided

201 in s. 287.057(3)(e)12., or unless otherwise authorized by

202 statute. If the purchasing agency, after consultation with the

203 commission, determines that it cannot reach mutually acceptable

204 contract terms with the commission, the purchasing agency may

205 contract for the same transportation services provided in a more

206 cost-effective manner and of comparable or higher quality and

207 standards. The Medicaid agency shall implement this subsection

208 in a manner consistent with s. 409.908(19) ~~s. 409.908(18)~~ and as

209 otherwise limited or directed by the General Appropriations Act.

210 Section 5. Subsections (1) and (5) of section 1011.70,

211 Florida Statutes, are amended to read:

212 1011.70 Medicaid certified school funding maximization.—

213 (1) Each school district, subject to the provisions of ss.

214 409.9071 and 409.908(22) ~~ss. 409.9071 and 409.908(21)~~ and this

215 section, is authorized to certify funds provided for a category

216 of required Medicaid services termed “school-based services,”

217 which are reimbursable under the federal Medicaid program. Such

218 services shall include, but not be limited to, physical,

219 occupational, and speech therapy services, behavioral health

220 services, mental health services, transportation services, Early

221 Periodic Screening, Diagnosis, and Treatment (EPSDT)

222 administrative outreach for the purpose of determining

223 eligibility for exceptional student education, and any other

224 such services, for the purpose of receiving federal Medicaid

225 financial participation. Certified school funding shall not be

226 available for the following services:

227 (a) Family planning.

228 (b) Immunizations.

229 (c) Prenatal care.

230 (5) Lab schools, as authorized under s. 1002.32, shall be

231 authorized to participate in the Medicaid certified school match

232 program on the same basis as school districts subject to the

233 provisions of subsections (1)-(4) and ss. 409.9071 and

234 409.908(22) ~~ss. 409.9071 and 409.908(21)~~ .

235 Section 6. For the purpose of incorporating the amendment

236 made by this act to section 409.967, Florida Statutes, in a

237 reference thereto, paragraph (c) of subsection (3) of section

238 409.966, Florida Statutes, is reenacted to read:

239 409.966 Eligible plans; selection.—

240 (3) QUALITY SELECTION CRITERIA.—

241 (c) After negotiations are conducted, the agency shall

242 select the eligible plans that are determined to be responsive

243 and provide the best value to the state. Preference shall be

244 given to plans that:

245 1. Have signed contracts with primary and specialty

246 physicians in sufficient numbers to meet the specific standards

247 established pursuant to s. 409.967(2)(c).

248 2. Have well-defined programs for recognizing patient

249 centered medical homes and providing for increased compensation

250 for recognized medical homes, as defined by the plan.

251 3. Are organizations that are based in and perform

252 operational functions in this state, in-house or through

253 contractual arrangements, by staff located in this state. Using

254 a tiered approach, the highest number of points shall be awarded

255 to a plan that has all or substantially all of its operational

256 functions performed in the state. The second highest number of

257 points shall be awarded to a plan that has a majority of its

258 operational functions performed in the state. The agency may

259 establish a third tier; however, preference points may not be

260 awarded to plans that perform only community outreach, medical

261 director functions, and state administrative functions in the

262 state. For purposes of this subparagraph, operational functions

263 include corporate headquarters, claims processing, member

264 services, provider relations, utilization and prior

265 authorization, case management, disease and quality functions,

266 and finance and administration. For purposes of this

267 subparagraph, the term “corporate headquarters” means the

268 principal office of the organization, which may not be a

269 subsidiary, directly or indirectly through one or more

270 subsidiaries of, or a joint venture with, any other entity whose

271 principal office is not located in the state.

272 4. Have contracts or other arrangements for cancer disease

273 management programs that have a proven record of clinical

274 efficiencies and cost savings.

275 5. Have contracts or other arrangements for diabetes

276 disease management programs that have a proven record of

277 clinical efficiencies and cost savings.

278 6. Have a claims payment process that ensures that claims

279 that are not contested or denied will be promptly paid pursuant

280 to s. 641.3155.

281 Section 7. For the purpose of incorporating the amendment

282 made by this act to section 409.967, Florida Statutes, in a

283 reference thereto, subsection (1) of section 409.975, Florida

284 Statutes, is reenacted to read:

285 409.975 Managed care plan accountability.—In addition to

286 the requirements of s. 409.967, plans and providers

287 participating in the managed medical assistance program shall

288 comply with the requirements of this section.

289 (1) PROVIDER NETWORKS.—Managed care plans must develop and

290 maintain provider networks that meet the medical needs of their

291 enrollees in accordance with standards established pursuant to

292 s. 409.967(2)(c). Except as provided in this section, managed

293 care plans may limit the providers in their networks based on

294 credentials, quality indicators, and price.

295 (a) Plans must include all providers in the region that are

296 classified by the agency as essential Medicaid providers, unless

297 the agency approves, in writing, an alternative arrangement for

298 securing the types of services offered by the essential

299 providers. Providers are essential for serving Medicaid

300 enrollees if they offer services that are not available from any

301 other provider within a reasonable access standard, or if they

302 provided a substantial share of the total units of a particular

303 service used by Medicaid patients within the region during the

304 last 3 years and the combined capacity of other service

305 providers in the region is insufficient to meet the total needs

306 of the Medicaid patients. The agency may not classify physicians

307 and other practitioners as essential providers. The agency, at a

308 minimum, shall determine which providers in the following

309 categories are essential Medicaid providers:

310 1. Federally qualified health centers.

311 2. Statutory teaching hospitals as defined in s.

312 408.07(46).

313 3. Hospitals that are trauma centers as defined in s.

314 395.4001(15).

315 4. Hospitals located at least 25 miles from any other

316 hospital with similar services.

318 Managed care plans that have not contracted with all essential

319 providers in the region as of the first date of recipient

320 enrollment, or with whom an essential provider has terminated

321 its contract, must negotiate in good faith with such essential

322 providers for 1 year or until an agreement is reached, whichever

323 is first. Payments for services rendered by a nonparticipating

324 essential provider shall be made at the applicable Medicaid rate

325 as of the first day of the contract between the agency and the

326 plan. A rate schedule for all essential providers shall be

327 attached to the contract between the agency and the plan. After

328 1 year, managed care plans that are unable to contract with

329 essential providers shall notify the agency and propose an

330 alternative arrangement for securing the essential services for

331 Medicaid enrollees. The arrangement must rely on contracts with

332 other participating providers, regardless of whether those

333 providers are located within the same region as the

334 nonparticipating essential service provider. If the alternative

335 arrangement is approved by the agency, payments to

336 nonparticipating essential providers after the date of the

337 agency’s approval shall equal 90 percent of the applicable

338 Medicaid rate. Except for payment for emergency services, if the

339 alternative arrangement is not approved by the agency, payment

340 to nonparticipating essential providers shall equal 110 percent

341 of the applicable Medicaid rate.

342 (b) Certain providers are statewide resources and essential

343 providers for all managed care plans in all regions. All managed

344 care plans must include these essential providers in their

345 networks. Statewide essential providers include:

346 1. Faculty plans of Florida medical schools.

347 2. Regional perinatal intensive care centers as defined in

348 s. 383.16(2).

349 3. Hospitals licensed as specialty children’s hospitals as

350 defined in s. 395.002(28).

351 4. Accredited and integrated systems serving medically

352 complex children which comprise separately licensed, but

353 commonly owned, health care providers delivering at least the

354 following services: medical group home, in-home and outpatient

355 nursing care and therapies, pharmacy services, durable medical

356 equipment, and Prescribed Pediatric Extended Care.

357 5. Florida cancer hospitals that meet the criteria in 42

358 U.S.C. s. 1395ww(d)(1)(B)(v).

360 Managed care plans that have not contracted with all statewide

361 essential providers in all regions as of the first date of

362 recipient enrollment must continue to negotiate in good faith.

363 Payments to physicians on the faculty of nonparticipating

364 Florida medical schools shall be made at the applicable Medicaid

365 rate. Payments for services rendered by regional perinatal

366 intensive care centers shall be made at the applicable Medicaid

367 rate as of the first day of the contract between the agency and

368 the plan. Except for payments for emergency services, payments

369 to nonparticipating specialty children’s hospitals, and payments

370 to nonparticipating Florida cancer hospitals that meet the

371 criteria in 42 U.S.C. s. 1395ww(d)(1)(B)(v), shall equal the

372 highest rate established by contract between that provider and

373 any other Medicaid managed care plan.

374 (c) After 12 months of active participation in a plan’s

375 network, the plan may exclude any essential provider from the

376 network for failure to meet quality or performance criteria. If

377 the plan excludes an essential provider from the plan, the plan

378 must provide written notice to all recipients who have chosen

379 that provider for care. The notice shall be provided at least 30

380 days before the effective date of the exclusion. For purposes of

381 this paragraph, the term “essential provider” includes providers

382 determined by the agency to be essential Medicaid providers

383 under paragraph (a) and the statewide essential providers

384 specified in paragraph (b).

385 (d) The applicable Medicaid rates for emergency services

386 paid by a plan under this section to a provider with which the

387 plan does not have an active contract shall be determined

388 according to s. 409.967(2)(b).

389 (e) Each managed care plan may offer a network contract to

390 each home medical equipment and supplies provider in the region

391 which meets quality and fraud prevention and detection standards

392 established by the plan and which agrees to accept the lowest

393 price previously negotiated between the plan and another such

394 provider.

395 Section 8. For the purpose of incorporating the amendment

396 made by this act to section 409.967, Florida Statutes, in a

397 reference thereto, paragraph (b) of subsection (4) of section

398 409.9855, Florida Statutes, is reenacted to read:

399 409.9855 Pilot program for individuals with developmental

400 disabilities.—

401 (4) ELIGIBLE PLANS; PLAN SELECTION.—

402 (b) The agency shall select, as provided in s. 287.057(1),

403 one plan to participate in the pilot program for each of the two

404 regions. The director of the Agency for Persons with

405 Disabilities or his or her designee must be a member of the

406 negotiating team.

407 1. The invitation to negotiate must specify the criteria

408 and the relative weight assigned to each criterion that will be

409 used for determining the acceptability of submitted responses

410 and guiding the selection of the plans with which the agency and

411 the Agency for Persons with Disabilities negotiate. In addition

412 to any other criteria established by the agency, in consultation

413 with the Agency for Persons with Disabilities, the agency shall

414 consider the following factors in the selection of eligible

415 plans:

416 a. Experience serving similar populations, including the

417 plan’s record in achieving specific quality standards with

418 similar populations.

419 b. Establishment of community partnerships with providers

420 which create opportunities for reinvestment in community-based

421 services.

422 c. Provision of additional benefits, particularly

423 behavioral health services, the coordination of dental care, and

424 other initiatives that improve overall well-being.

425 d. Provision of and capacity to provide mental health

426 therapies and analysis designed to meet the needs of individuals

427 with developmental disabilities.

428 e. Evidence that an eligible plan has written agreements or

429 signed contracts or has made substantial progress in

430 establishing relationships with providers before submitting its

431 response.

432 f. Experience in the provision of person-centered planning

433 as described in 42 C.F.R. s. 441.301(c)(1).

434 g. Experience in robust provider development programs that

435 result in increased availability of Medicaid providers to serve

436 the developmental disabilities community.

437 2. After negotiations are conducted, the agency shall

438 select the eligible plans that are determined to be responsive

439 and provide the best value to the state. Preference must be

440 given to plans that:

441 a. Have signed contracts in sufficient numbers to meet the

442 specific standards established under s. 409.967(2)(c), including

443 contracts for personal supports, skilled nursing, residential

444 habilitation, adult day training, mental health services,

445 respite care, companion services, and supported employment, as

446 those services are defined in the Florida Medicaid Developmental

447 Disabilities Individual Budgeting Waiver Services Coverage and

448 Limitations Handbook as adopted by reference in rule 59G-13.070,

449 Florida Administrative Code.

450 b. Have well-defined programs for recognizing patient

451 centered medical homes and providing increased compensation to

452 recognized medical homes, as defined by the plan.

453 c. Have well-defined programs related to person-centered

454 planning as described in 42 C.F.R. s. 441.301(c)(1).

455 d. Have robust and innovative programs for provider

456 development and collaboration with the Agency for Persons with

457 Disabilities.

458 Section 9. This act shall take effect July 1, 2026.