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HB 1097 2026
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hb1097-00
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
A bill to be entitled 1
An act relating to health insurer accountability; 2
amending s. 408.7057, F.S.; requiring a health plan to 3
participate in a filed claim dispute; providing 4
penalties for failure to respond to a claim; requiring 5
the Agency for Health Care Administration to notify a 6
certain entity within a specified timeframe when a 7
health plan fails to pay a provider under certain 8
circumstances; requiring a health plan to pay a 9
provider within a specified timeframe after the 10
agency's order; providing penalties; amending s. 11
409.967, F.S.; providing credentialing requirements 12
for a managed care plan; requiring each managed care 13
plan to identify to the agency and the Office of 14
Insurance Regulation any ownership interest or 15
affiliation of any kind with certain entities; 16
providing requirements for the identification of such 17
information; requiring each managed care plan to 18
report specified information to the agency and the 19
office in writing within a specified timeframe; 20
removing a provision requiring the results of certain 21
audit reports to be dispositive; amending s. 409.975, 22
F.S.; requiring managed care contracts to include 23
provider notifications regarding certain denials of 24
coverage; amending ss. 627.6131 and 641.315, F.S.; 25
HB 1097 2026
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
prohibiting an insurer from denying certain claims 26
under certain circumstances; providing notification 27
requirements and penalties; amending ss. 409.973 and 28
409.9855, F.S.; conforming cross-references; providing 29
an effective date. 30
31
Be It Enacted by the Legislature of the State of Florida: 32
33
Section 1. Subsection (7) of section 408.7057, Florida 34
Statutes, is renumbered as subsection (8), subsection (5) is 35
amended, paragraph (i) is added to subsection (2), and a new 36
subsection (7) is added to that section, to read: 37
408.7057 Statewide provider and health plan claim dispute 38
resolution program.— 39
(2) 40
(i) A health plan must participate in a filed claim 41
dispute. Failure to respond as provided in paragraph (f) shall 42
result in a default against the health plan. 43
(5) The agency shall notify within 7 days the appropriate 44
licensure or certification entity whenever there is: 45
(a) A failure to pay as provided in subsection (7); or 46
(b) A violation of a final order issued by the agency 47
pursuant to this section. 48
(7) A health plan that does not prevail in the agency's 49
order shall pay the provider the amount provided in the order 50
HB 1097 2026
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
within 35 days after the order is entered. A health plan that 51
does not pay the required amount within the required timeframe 52
is subject to a penalty of up to $500 per day until the amount 53
is paid. 54
Section 2. Subsections (3) and (4) of section 409.967, 55
Florida Statutes, are renumbered as subsections (4) and (5), 56
respectively, paragraph (e) of present subsection (3) is 57
amended, paragraphs (p) and (q) are added to subsection (2), and 58
a new subsection (3) is added to that section, to read: 59
409.967 Managed care plan accountability.— 60
(2) The agency shall establish such contract requirements 61
as are necessary for the operation of the statewide managed care 62
program. In addition to any other provisions the agency may deem 63
necessary, the contract must require: 64
(p) Credentialing.— 65
1. A managed care plan shall determine whether it will 66
contract with a provider within 30 calendar days after receipt 67
of the verified credentialing information from a credentialing 68
verification organization either designated by the agency or 69
contracted by managed care organizations as part of a 70
credentialing alliance. Within 15 days after a contract is 71
executed, a managed care plan shall ensure that any internal 72
processing systems of the managed care plan have been updated to 73
include: 74
a. The accepted provider contract. 75
HB 1097 2026
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
b. The provider as a participating provider. 76
2. For the purpose of reimbursement of claims, once a 77
provider has met the terms and conditions for credentialing and 78
enrollment, the provider's credentialing application date shall 79
be the date from which the provider's claims become eligible for 80
payment. 81
3. A managed care plan may not require a provider to 82
appeal or resubmit any clean claim submitted during the time 83
period between the provider's credentialing application date and 84
the completion of the credentialing process. 85
(q) Ownership interest or affiliation.— 86
1. Each managed care plan shall identify to the agency and 87
the Office of Insurance Regulation any ownership interest or 88
affiliation of any kind with any provider, provider group, or 89
company responsible for providing any pharmacy, diagnostics, 90
care coordination, care delivery, direct health care services, 91
administrative services, or financial services. 92
2. Each managed care plan shall also identify to the 93
agency and the Office of Insurance Regulation any ownership 94
affiliation of any kind with any entity which, either directly 95
or indirectly, through one or more intermediaries: 96
a. Has an investment or ownership interest of any kind 97
with any entity providing pharmacy, diagnostics, care 98
coordination, care delivery, direct health care services, or 99
administrative services; 100
HB 1097 2026
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
b. Shares common ownership with any entity providing 101
pharmacy, diagnostics, care coordination, care delivery, direct 102
health care services, or administrative services; or 103
c. Has an investor or a holder of an ownership interest of 104
any kind with any entity providing pharmacy, diagnostics, care 105
coordination, care delivery, direct health care services, or 106
administrative services. 107
(3) Each managed care plan shall report any change in 108
information in subsection (2) to the agency and the Office of 109
Insurance Regulation in writing within 60 days after the change 110
occurs. 111
(4)(3) ACHIEVED SAVINGS REBATE.— 112
(e) Once the certified public accountant completes the 113
audit, the certified public accountant shall submit an audit 114
report to the agency attesting to the achieved savings of the 115
plan. The agency shall review the report to determine compliance 116
with the requirements of this subsection. The agency shall 117
notify the certified public accountant of any deficiencies in 118
the audit report. The certified public accountant must correct 119
such deficiencies in the audit report and resubmit the revised 120
audit report to the agency before the report is considered 121
final. Once finalized, the results of the audit report are 122
dispositive. 123
Section 3. Subsection (7) is added to section 409.975, 124
Florida Statutes, to read: 125
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
409.975 Managed care plan accountability.—In addition to 126
the requirements of s. 409.967, plans and providers 127
participating in the managed medical assistance program shall 128
comply with the requirements of this section. 129
(7) PROVIDER NOTIFICATION REQUIREMENT.—Each managed care 130
contract with a provider must include provider notifications 131
regarding denials of coverage in accordance with ss. 132
627.6131(22) and 641.315(15). 133
Section 4. Subsection (22) is added to section 627.6131, 134
Florida Statutes, to read: 135
627.6131 Payment of claims.— 136
(22) For circumstances in subparagraph (21)(a)1. and sub-137
subparagraphs (21)(a)5.d. and e., an insurer may not deny a 138
claim of a previously authorized health care service unless the 139
insurer has notified both the insured and the treating provider 140
of the insured's change in coverage status or applicable benefit 141
limitation. Notification to the provider must be issued 142
contemporaneously with the notice required to be given to the 143
insured under this section. Failure to provide such notification 144
shall preclude the insurer from denying payment for the 145
authorized service. 146
Section 5. Subsection (15) is added to section 641.315, 147
Florida Statutes, to read: 148
641.315 Provider contracts.— 149
(15) For circumstances in subparagraph (14)(a)1. and sub-150
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
subparagraphs (14)(a)5.d. and e., an insurer may not deny a 151
claim of a previously authorized health care service unless the 152
insurer has notified both the insured and the treating provider 153
of the insured's change in coverage status or applicable benefit 154
limitation. Notification to the provider must be issued 155
contemporaneously with the notice required to be given to the 156
insured under this section. Failure to provide such notification 157
shall preclude the insurer from denying payment for the 158
authorized service. 159
Section 6. Paragraph (b) of subsection (5) of section 160
409.973, Florida Statutes, is amended to read: 161
409.973 Benefits.— 162
(5) PROVISION OF DENTAL SERVICES.— 163
(b) In the event the Legislature takes no action before 164
July 1, 2017, with respect to the report findings required under 165
paragraph (a), the agency shall implement a statewide Medicaid 166
prepaid dental health program for children and adults with a 167
choice of at least two licensed dental managed care providers 168
who must have substantial experience in providing dental care to 169
Medicaid enrollees and children eligible for medical assistance 170
under Title XXI of the Social Security Act and who meet all 171
agency standards and requirements. To qualify as a provider 172
under the prepaid dental health program, the entity must be 173
licensed as a prepaid limited health service organization under 174
part I of chapter 636 or as a health maintenance organization 175
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F L O R I D A H O U S E O F R E P R E S E N T A T I V E S
under part I of chapter 641. The contracts for program providers 176
shall be awarded through a competitive procurement process. 177
Beginning with the contract procurement process initiated during 178
the 2023 calendar year, the contracts must be for 6 years and 179
may not be renewed; however, the agency may extend the term of a 180
plan contract to cover delays during a transition to a new plan 181
provider. The agency shall include in the contracts a medical 182
loss ratio provision consistent with s. 409.967(5) s. 183
409.967(4). The agency is authorized to seek any necessary state 184
plan amendment or federal waiver to commence enrollment in the 185
Medicaid prepaid dental health program no later than March 1, 186
2019. The agency shall extend until December 31, 2024, the term 187
of existing plan contracts awarded pursuant to the invitation to 188
negotiate published in October 2017. 189
Section 7. Paragraph (c) of subsection (5) of section 190
409.9855, Florida Statutes, is amended to read: 191
409.9855 Pilot program for individuals with developmental 192
disabilities.— 193
(5) PAYMENT.— 194
(c) The revenues and expenditures of the selected plan 195
which are associated with the implementation of the pilot 196
program must be included in the reporting and regulatory 197
requirements established in s. 409.967(4) s. 409.967(3). 198
Section 8. This act shall take effect July 1, 2026. 199