No. HB 531
Filed under Healthcare.
Managed Care Plans; Revises Medicaid managed care contract requirements to prohibit managed care plans from reviewing certain prior authorization claims for medical necessity; requires that managed care plans provide coverage for durable medical equipment & complex rehabilitation technology from qualified provider, from within provider network, of enrollee's choosing; requires AHCA to adopt certain rules.
Plain English Summary
AI-GENERATEDOnce a Medicaid managed care plan has given prior authorization for equipment, supplies, or services, it can no longer deny or claw back payment by reopening the medical-necessity question, whether the review happens before or after payment.
Managed care plans and their subcontractors must cover durable medical equipment and complex rehabilitation technology from whichever qualified in-network provider the enrollee picks, rather than steering them to a single preferred vendor.
The state agency must write rules guaranteeing that provider choice and must add a specific complaint procedure to the existing grievance process for enrollees denied that choice.
The medical-necessity provision is not written as DME-specific, so it appears to protect any previously authorized Medicaid managed care claim, not just equipment and rehabilitation technology.
AIOnce a Medicaid managed care plan has given prior authorization for equipment, supplies, or services, it may not later deny or claw back payment by reopening the question of medical necessity, whether the review happens before or after payment.
AIManaged care plans and their subcontractors must cover durable medical equipment and complex rehabilitation technology from whichever qualified provider the enrollee picks, as long as that provider is within the plan's network.
AIThe agency must adopt rules specifically authorizing enrollees to pick their durable medical equipment or complex rehabilitation technology provider from among in-network options.
AIEnrollees who believe they were denied the right to choose their own in-network durable medical equipment provider get a specific complaint procedure inside the existing grievance resolution process.