THE BILL ITSELF
CS/HB 517
Medicaid Provider Networks
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A bill to be entitled
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An act relating to Medicaid provider networks;
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amending s. 409.967, F.S.; requiring the Agency for
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Health Care Administration to establish network
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adequacy standards for prepaid dental plans; providing
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requirements for such standards; requiring Medicaid
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managed care plan provider network databases to
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identify whether providers are accepting new patients;
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requiring prepaid dental plans to provide specified
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information on the online provider database; providing
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an effective date.
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Be It Enacted by the Legislature of the State of Florida: Section 1. Paragraph (c) of subsection (2) of section
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409.967, Florida Statutes, is amended to read:
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409.967 Managed care plan accountability.—
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(2) The agency shall establish such contract requirements
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as are necessary for the operation of the statewide managed care
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program. In addition to any other provisions the agency may deem
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necessary, the contract must require:
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(c) Access.—
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1. The agency shall establish specific standards for the
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number, type, and regional distribution of providers in managed
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care plan networks to ensure access to care for both adults and
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children.
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a. Each plan must maintain a regionwide network of
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providers in sufficient numbers to meet the access standards for
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specific medical services for all recipients enrolled in the
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plan. The exclusive use of mail-order pharmacies may not be
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sufficient to meet network access standards. Consistent with the
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standards established by the agency, provider networks may
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include providers located outside the region. The agency shall
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establish a specific network adequacy standard, with time and
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distance travel standards, for each provider type and specialty
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service covered by prepaid dental plans, and shall establish a
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standard for each level of sedation dentistry. The standards for
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sedation dentistry shall ensure sufficient capacity to ensure
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all enrollees who require sedation dentistry as medically
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necessary may access at least two preventive or treatment
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appointments per year. The time and distance travel standards
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for sedation dentistry shall be no more than the standards for
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general dentistry.
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b. Each plan shall establish and maintain an accurate and
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complete electronic database of contracted providers, including
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information about licensure or registration, locations and hours
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of operation, specialty credentials and other certifications,
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specific performance indicators, whether the provider is
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accepting additional Medicaid patients, and such other
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information as the agency deems necessary. The database must be
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available online to both the agency and the public and have the
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capability to compare the availability of providers to network
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adequacy standards and to accept and display feedback from each
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provider's patients. For prepaid dental plans, the online
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provider database must clearly identify sedation dentistry
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providers, list specialty providers separately from general
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dentists, and specifically identify the specialty services
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offered by each provider. Each plan shall submit quarterly
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reports to the agency identifying the number of enrollees
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assigned to each primary care provider.
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c. The agency shall conduct, or contract for, systematic
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and continuous testing of the provider network databases
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maintained by each plan to confirm accuracy, confirm that
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behavioral health providers are accepting enrollees, and confirm
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that enrollees have access to behavioral health services.
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2. Each managed care plan must publish any prescribed drug
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formulary or preferred drug list on the plan's website in a
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manner that is accessible to and searchable by enrollees and
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providers. The plan must update the list within 24 hours after
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making a change. Each plan must ensure that the prior
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authorization process for prescribed drugs is readily accessible
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to health care providers, including posting appropriate contact
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information on its website and providing timely responses to
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providers. For Medicaid recipients diagnosed with hemophilia who
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have been prescribed anti-hemophilic-factor replacement
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products, the agency shall provide for those products and
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hemophilia overlay services through the agency's hemophilia
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disease management program.
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3. Managed care plans, and their fiscal agents or
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intermediaries, must accept prior authorization requests for any
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service electronically.
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4. Managed care plans serving children in the care and
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custody of the Department of Children and Families must maintain
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complete medical, dental, and behavioral health encounter
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information and participate in making such information available
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to the department or the applicable contracted community-based
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care lead agency for use in providing comprehensive and
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coordinated case management. The agency and the department shall
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establish an interagency agreement to provide guidance for the
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format, confidentiality, recipient, scope, and method of
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information to be made available and the deadlines for
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submission of the data. The scope of information available to
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the department shall be the data that managed care plans are
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required to submit to the agency. The agency shall determine the
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plan's compliance with standards for access to medical, dental,
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and behavioral health services; the use of medications; and
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followup on all medically necessary services recommended as a
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result of early and periodic screening, diagnosis, and
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treatment.
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Section 2. This act shall take effect July 1, 2026.